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PRINCIPLES  AND  PRACTICE 

OF 

FILLING  TEETH 


JOHNSON 


A  TEXT-BOOK 

OF 

OPERATIVE  DENTISTRY 

By  Various  Authors 

EDITED  BY 

C.  N.  JOHNSON,  M.A.,L.D.S.,D.D.S. 

Third  Edition,  Revised.     805  Illustrations. 
Octavo,    xiv+891  Pages. 

Cloth,  $6.00  net 

P.      BLAKISTON'S      SON     &      CO. 

Publishers,  Philadelphia 


PRINCIPLES  AND  PRACTICE 

OF 

FILLING  TEETH 


BY 

C.  N.  JOHNSON,  M.A.,  L.D.S.,  D.D.S. 

PROFESSOR  OF   OPERATIVE  DENTISTRY  IX  THE  CHICAGO 
COLLEGE   OF  DENTAL  SURGERY,   EDITOR  OF 

THE  Dental  Review. 


FOURTH  EDITION 
REVISED  AND   ENLARGED 


WITH  127  ILLUSTRATIONS 


PHILADELPHIA 

P.   BLAKISTON'S   SON   &  CO. 

1012   WALNUT   STREET 


Copyright,  1918,  by  P.  Blakiston's  Son  &  Co. 


THE     M:AI"1,E     press     YORK    T  A. 


PREFACE  TO  THE  FOURTH  EDITION 

For  the  Fourth  Edition  of  this  work  a  more  extensive  revision 
has  been  made  than  for  any  previous  issue.  This  has  been 
rendered  necessary  by  the  very  considerable  change  in  ideas 
regarding  some  of  the  modern  methods  of  practice.  In  recent 
years  the  cast  gold  inlay  has  assumed  a  definite  status  in  our 
daily  work,  and  accordingly  the  chapter  on  this  subject  has  been 
entirely  re-written.  Root  canal  work  is  clainiing  unusual  atten- 
tion by  the  profession,  and  this  therefore  has  been  considered  in 
some  detail.  The  subject  of  oral  prophylaxis  is  an  increasingly 
important  one,  with  great  possibilities  for  future  usefulness,  and 
it  has  been  deemed  necessary  to  go  into  it  with  some  care.  Little 
change  has  been  made  in  the  Chapters  on  Cavity  Preparation, 
this  work  having  been  standardized  and  placed  on  a  stable  basis 
years  ago. 

The  rapid  evolution  of  ideas  in  many  of  the  lines  of  practice 
in  operative  dentistry  renders  constant  revision  necessary  in  a 
work  of  this  kind,  and  the  author  can  only  hope  that  this  edition 
may  prove  satisfactory  to  his  readers.  If  they  are  as  charitable 
of  the  limitations  of  the  present  volume  as  they  have  been  of  the 
previous  issues,  it  is  all  that  he  can  ask. 

C.  N.  J. 

Chicago. 


CONTENTS 


PAGE 

xi 


INTRODUCTORY 

CHAPTER  I ; ^ 

Deposits  on  the  Teeth.  Ivinds  of  Deposits. — Salivary  Cal- 
culus.—Serumal  Calculus.— Stains  on  the  Teeth.  Removal  of 
Deposits.  Removal  of  Salivary  Calculus.— Instruments.— Tech- 
iiique.— Removal  of  Serumal  Calculus.— Removal  of  Stains  from 
the  Teeth.— Oral  Prophyla.xis.— Instructions  to  Patients  as  to  the 
Care  of  the  Teeth. 

CHAPTER  II 25 

Dental  Caries. 

CHAPTER  III ^"^ 

Examination  of  the  Teeth  for  Caries.  Appliances  for  Ex- 
amining the  Teeth. 

CHAPTER  IV ; *^ 

Exclusion  of  Moisture  During  Operations.  End  of  Rub- 
ber Dam.— Size  of  Dam.— Punching  the  Holes  in  Rubber  Dam.— 
Rubber-Dam  Clamps.— Clamps  for  Molars  and  Bicuspids.— Cer- 
vical Clamps  for  Buccal,  Labial,  or  Lingual  Cavities.— Ligatures.— 
Manner  of  Applying  the  Dam  in  the  Different  Locations  in  the 
Mouth.— Apphcation  of  Dam  in  Difficult  Cases.— Use  of  Napkins 
and  Cotton  Rolls  for  Maintaining  Dryness  During  Operations. 

CHAPTER  V •  ■  •  • : ^1 

Classification  and  Preparation  of  Cavities.  Cavity  Prepa- 
ration.— Simple  Proximal  Cavities  in  Incisors  and  Cuspids. — Sepa- 
arating  the  Teeth.— Detail  of  Cavity  Formation.— General  Con- 
siderations.—Proximal  Cavities  in  Anterior  Teeth  Involving  the 
Incisal  Angle.— Detail  of  Cavity  Formation.- General  Considera- 
tions.—Proximal  Cavities  in  Bicuspids  and  Molars.— Simple  Proxi- 
mal Cavities  not  Involving  Other  Surfaces.— Proximo-Occlusal 
Cavities  in  Bicuspids  and  Molars.— The  Interproximal  Space.— 
Separating  the  Teeth.— Details  of  Cavity  Formation.— General 
Considerations.— Buccal,  Labial,  or  Lingual  Cavities.— Occlusal 
Cavities  in  Bicuspids  and  Molars.— The  Treatment  of  Softened 
Dentin  in  Deep-Seated  Cavities.— Hypersensitive  Dentin. 

CHAPTER  VI 13^ 

Filling-Materials.  Gold  and  its  Combinations. — Gold-and- 
Platinum.—  Gold-and-Tin.— Amalgam.— Tin.— Cements.— Gutta- 
percha.— The  Sihcate  Cements. — Inlays. 

vii 


Vlll  CONTENTS 

Page 

CHAPTER  VII. 150 

Gold.  Cohesive  and  Non-Cohesive  Gold. — Annealing  Gold. — 
Different  Forms  of  Gold. — Crystal  Golds. 

CHAPTER  VIII 161 

Mallets  and  Malleting.  The  Hand  Mallet. — The  Automatic 
Mallet. — The  Rapid  Mallets.— Hand  Pressure. — Protection  to  the 
Peridental  Membrane  in  Malleting. 

CHAPTER  IX 174 

.  The  Introduction,  Condensation,  and  Finishing  op  Gold 
Fillings  in  the  Different  Classes  of  Cavities.  Simple  Proxi- 
mal Gold  Fillings  in  Incisors. — Pluggers. — Finishing  Proximal  Fill- 
ings in  Incisors. — Proximal  Fillings  in  Anterior  Teeth  Involving 
the  Incisal  Angle. — Fillings  in  Proximo-Occlusal  Cavities  in 
Bicuspids  and  Molars. — The  Matrix. — Disto-Occlusal  Fillings  in 
Left  Lower  Bicuspids  and  Molars. — Pluggers. — Finishing  Filhngs. 
— Disto-Occlusal  Fillings  in  Right  Lower  Bicuspids  and  Molars. — ■ 
Disto-Occlusal  Fillings  in  Upper  Bicuspids  and  Molars. — Mesio- 
Occlusal  Fillings  in  Bicuspids  and  Molars. — Occlusal  Fillings  in 
Bicuspids  and  Molars. — Buccal,  Labial,  or  Lingual  Fillings. 

CHAPTER  X 195 

Manipulation  of  Platinum-and-Gold  in  Filling  Teeth. 

CHAPTER  XI 197 

Manipulation  op  Tin-and-Gold. 

CHAPTER  XII 201 

Manipulation  of  Amalgam.     Method  of  Packing  Amalgam. 

CHAPTER  XIII 206 

Manipulation  of  Cements. 

CHAPTER  XIV 208 

Manipulation  of  Gutta-Percha. 

CHAPTER  XV 210 

Manipulation  of  Silicate  Cements. 

CHAPTER  XVI 212 

Making  Inlay  Fillings.  Porcelain  Inlays. — Detail  of  Cavity 
Preparation  for  Inlays. — Fitting  the  Matrix. — Taking  an  Impres- 
sion of  the  Cavity. — Adapting  the  Matrix  to  the  Cavity  in  the 
Tooth. — Porcelain  Bodies. — Matching  Shades. — Baking  the  Porce- 
lain.— Making  Gold  Inlays. — Direct  and  Indirect  Methods  of 
Making  Inlays. 

CHAPTER  XVII 234 

Pulp-Capping.  Materials  for  Capping  Pulps. — Method  of  Cap- 
ping Pulps. 


CONTENTS  IX 

Page 

CHAPTER  XVIII 241 

Destruction  of  the  Pulp.  Destroying  the  Pulp  with  Arsenic. 
— Removing  the  Pulp  with  Pressure  Anesthesia. — Removal  of  the 
Pulp. 

CHAPTER  XIX 249 

Filling  Pulp-Canals. 

CHAPTER  XX 2.56 

The  X-ray  in  the  Management  of  Pulpless  Teeth.  The 
Z-ray  as  a  Diagnostic  Aid  in  Determining  the  Presence  or 
Absence  of  Infection  in  the  Apical  Region. 

CHAPTER  XXI 261 

The  Treatment  of  Putrescent  Pulp  Canals.  Treatment  of 
Pulpless  Teeth  where  the  Canals  have  long  been  Exposed  to  the 
Fluids  of  the  Mouth,  but  where  there  is  no  Sinous  Opening. — 
Treatment  of  Pulpless  Teeth  having  a  Sinous  Opening  on  Gum. 
— Opening  into  Filled  Teeth  in  which  Pulps  have  Died,  but  Lain 
Dormant. — Management  of  Pulpless  Teeth  in  Anterior  Part  of 
Mouth  to  Prevent  Discoloration. — Bleaching  Teeth. 

CHAPTER  XXII 272 

The  Management  or  Children's  Teeth.  Management  of  the 
Deciduous  Teeth. — Treatment  of  Exposed  Pulps  in  Deciduous 
Teeth. — Treatment  of  Abscessed  Deciduous  Teeth. — The  JNIanage- 
ment  of  Permanent  Teeth  in  Childhood. 

INDEX 283 


INTRODUCTORY 


The  problem  of  preventing  or  controlling  caries  of  the  teeth  is 
one  which  enters  very  materially  into  the  health,  longevity,  and 
happiness  of  the  human  race.  Apparently  we  are  not  yet  able  to 
prevent  decay,  and  it  thus  becomes  imperative  that  we  study  the 
best  means  of  checking  and  controlling  it.  When  caries  occurs 
on  any  surface  of  a  tooth  the  dentist  should  study  carefully  the 
conditions  which  brought  it  about,  and  should  aim  in  his  opera- 
tions so  to  change  those  conditions  that  caries  will  not  be  hkely 
to  recur. 

Too  many  practitioners  are  in  the  habit  of  following  their  work 
day  after  day  in  a  thoughtless,  slip-shod  manner,  without  due  con- 
sideration of  the  principles  which  should  underHe  all  operative 
procedures,  and  without  a  proper  study  of  the  relations  of  cause 
and  effect.  When  failures  occur,  as  they  do  in  the  hands  of  all 
practitioners — some  more,  some  less — the  most  profitable  lesson 
is  not  always  learned  thereby.  No  dentist  should  allow  himself 
to  pass  over  any  failure,  whether  his  own  or  another's,  without 
carefully  studying  the  particular  reasons  for  that  failure  and  the 
problems  which  must  be  solved  to  avoid  a  repetition  in  the  future. 
With  the  clearness  of  vision  which  should  eventually  result  from 
this  kind  of  study  the  practitioner  will  be  better  equipped  to 
serve  his  patrons,  and  his  failures  will  grow  perceptibly  fewer. 
If  all  dentists  would  bring  to  their  work  a  due  regard  for  this  form 
of  observation,  it  would  add  materially  to  the  permanence  of 
dental  service. 

In  the  consideration  of  the  present  subject  the  principal  aim 
will  be  to  direct  attention  to  some  of  the  causes  of  failure  in 
filling  teeth,  and  to  offer  suggestions  relative  to  possible  improve- 
ment in  methods  of  procedure.  In  doing  this  no  originality  of 
treatment  is  claimed.  The  thought  of  the  profession  in  recent 
years  has  been  too  active  along  these  lines  for  any  one  individual 
to  claim  much  in  the  way  of  originality.  But  some  of  the  recent 
advances  in  practice  would  seem  to  need  systematizing,  and  most 
of  them  require  emphasizing.     This  is  the  present  aim. 

The  plan  is  to  treat  the  various  topics  as  nearly  as  practicable  in 

xi 


XU  INTRODUCTORY 

the  order  of  their  performance  in  the  mouth;  to  give  in  detail  the 
consecutive  steps  of  the  operation,  and  to  say  something  of  the 
technique  of  the  subject.  This  latter  is  considered  to  be  of  very- 
great  importance,  but  it  is  a  matter  quite  difficult  of  intelligent 
treatment.  The  proper  selection  and  use  of  instruments  has 
much  to  do  with  the  effectiveness  of  our  work  and  the  comfort  of 
our  patients,  but  the  personal  equation  of  each  individual  opera- 
tor enters  so  prominently  into  the  question  that  it  is  difficult  to 
lay  down  rules  for  all  to  follow.  Then,  again,  there  is  such  a 
variation  in  patients  with  regard  to  their  toleration  of  different 
instruments  that  it  is  not  always  judicious  to  use  the  same  instru- 
ments in  the  same  way  on  all  patients.  We  must  study  carefully 
this  susceptibility  of  our  patients,  and  in  all  cases  where  it  will 
not  interfere  with  the  perfection  of  our  work  we  should  respect 
their  preference.  Some  individuals  will  submit  to  the  use  of 
hand  instruments,  such  as  excavators  and  chisels,  with  better 
grace  than  they  will  to  the  engine,  while  very  many  prefer  the 
smooth,  light  touch  of  a  rapidly  revolving  bur  to  the  grating, 
rasping  sensation  of  an  excavator.  In  the  routine  practice  of 
operating  there  are  some  stages  of  the  work  where  the  engine  is 
clearly  indicated,  and  some  where  hand  instruments  must  be  used, 
but  the  predominance  of  the  use  of  either  may  in  certain  instances 
be  determined  by  the  patient.  Not  that  we  should  in  any  sense 
allow  patients  to  dictate  to  us  how  we  shall  operate,  but  that 
we  may  often  profitably  study  their  varying  susceptibilities  to 
the  impressions  made  upon  them  by  different  instruments,  and 
govern  our  manipulation  somewhat  thereby. 

Much  in  the  way  of  prejudice  may  be  overcome  by  the  invari- 
able use  of  keen,  sharp  instruments  and  a  dexterous,  careful 
method  of  manipulation.  This  applies  as  well  to  the  engine  as 
to  hand  instruments.  The  dentist  should  cultivate  the  utmost 
4elicacy  of  touch,  so  as  to  impress  upon  his  patient  at  all  times 
the  fact  that  he  is  giving  the  least  possible  discomfort  commen- 
surate with  effective  work. 

The  system  of  technique  here  suggested  is  not  presented  as 
being  applicable  to  all  operators  or  all  patients.  It  is  not  even 
claimed  that  it  is  the  best  system,  but  merely  that  it  is  an  attempt 
to  formulate  a  definite  and  consecutive  method  of  procedure  in 
the  performance  of  many  of  our  operations,  which  in  the  past 
seem,  for  the  most  part,  to  have  been  performed  without  method 
and  without  system. 


PRINCIPLES  AND  PRACTICE  OF  FILLING  TEETH 

CHAPTER  I 

DEPOSITS  ON  THE  TEETH 

The  first  duty  of  the  dentist  when  a  patient  applies  to  him  for 
attention  to  the  natural  teeth  is  the  thorough  removal  of  all  de- 
posits, provided  the  patient  is  not  suffering  pain.  In  every  in- 
stance where  there  is  suffering  the  manifest  duty  of  the  profes- 
sional man  is  to  relieve  it  at  once  if  possible,  no  matter  in  what 
form  it  may  present  itself;  but  after  this  is  accomplished,  and  be- 
fore any  filling  operations  are  undertaken,  the  mouth  should  be 
put  in  as  nearly  a  hygienic  condition  as  may  be  secured  by  the  ut- 
most cleanliness.  It  is  too  often  the  case  that  operators — some 
of  them  with  a  brilliant  rcoord  as  skillful  manipulators — seem 
to  ignore  this  important  procedure,  and  hasten  to  the  insertion 
of  fillings  in  teeth  covered  with  calculus.  It  matters  not  how 
beautiful  or  how  perfect  an  operation  may  be  under  these  con- 
ditions, the  work  should  never  be  considered  as  ideal  dental 
service.  No  successful  architect  ever  builds  a  house  without 
first  looking  well  to  the  foundation,  and  no  surgeon  of  repute  will 
proceed  to  operate  upon  a  wound  without  at  least  making  the 
surrounding  parts  as  healthy  as  may  be  in  advance.  Dentists 
are  not  living  up  to  the  highest  possibilities  of  their  art  when  they 
fail  to  consider  the  importance  of  maintaining  the  tissues  around 
the  teeth  in  a  state  of  health,  and  this  cannot  be  done  short  of  a 
careful  removal  of  all  extraneous  material  which  may  be  found 
adherent  to  the  teeth.  It  would  seem  that  sufficient  emphasis 
had  been  given  this  matter  by  writers  in  the  past,  but  the  fact 
remains  that  with  all  that  has  been  said  the  profession  are  most 
lamentably  lax  when  it  comes  to  the  observance  of  true  hygiene 
of  the  mouth.  It  is  not  here  intended  to  make  an  unjust  arraign- 
ment of  the  profession  nor  charge  its  members  with  willful  neglect, 
but  the  persistent  ignoring  of  this  important  phase  of  practice  on 
the  part  of  many  otherwise  excellent  operators  constitutes  a  grave 

1 


2  PKINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

reflection  on  their  professional  integrity  and  correspondingly 
lowers  the  standard  of  dentistry.  The  people  can  be  educated 
in  this  matter  only  by  the  most  conscientious  and  earnest  effort 
of  their  dental  advisers,  and  no  man  practising  dentistry  is  doing 
his  full  duty  unless  his  patients  are  constantly  being  schooled 
into  the  necessity  for  painstaking  care  in  cleanliness  of  the  mouth. 
It  is  not  within  the  province  of  the  present  work  to  go  minutely 
into  the  pathology  of  this  subject,  and  yet  it  would  seem  desirable 
to  briefly  indicate  some  of  the  deleterious  effects  produced  by 
deposits  when  allowed  to  remain. 

The  encroachment  of  calculus  along  the  neck  and  root  of  a 
tooth,  if  left  unchecked,  results  in  an  absorption  of  the  gum,  the 
peridental  membrane,  and  even  the  alveolar  process,  so  that 
finally  the  support  of  the  tooth  is  destroyed,  and  it  is  allowed  to 
topple  over  and  fall  out.  It  is  estimated  by  many  observant 
practitioners  that  more  teeth  are  lost  as  the  result  of  diseased 
conditions  in  the  tissues  surrounding  them  than  from  decay  of  the 
teeth  themselves;  and,  if  this  be  true,  it  is  very  important  that 
dentists  should  pay  especial  attention  to  the  agencies  calculated 
to  bring  about  such  conditions.  It  is  undeniably  a  fact  that 
calculus  in  a  mouth  subject  to  its  continual  formation  will,  if 
allowed  to  accumulate,  sooner  or  later  work  the  destruction  of  the 
teeth. 


Fig.  1. 


Fig.  2. 


Fig.  3. 


Figs.  1,  2,  3,  4,  and  5  illustrate  some  extreme  cases  of  calculus 
formation  about  the  teeth.  Figs.  1  and  2  show  the  mesial  and 
distal  aspects  of  two  lower  incisors  with  calculus  attached,  actual 
size.  Fig.  3  is  a  mass  of  calculus  detached  from  the  buccal  sur- 
face of  an  upper  molar.  The  patient  applied  to  her  dentist  for 
examination  relative  to  some  "growth"  which  she  said  was  form- 
ing in  her  mouth,  and  the  result  was  the  removal  of  this  piece  of 


DEPOSITS    ON    THE   TEETH  6 

calculus,  here  reproduced  in  two  views,  actual  size.  Figs.  4  and  5 
are  specimens  of  calculus  attached  to  teeth,  one  a  lower  cuspid, 
the  other  an  upper  molar.  It  must  be  apparent  that  in  the  speci- 
mens shown  the  teeth  need  not  necessarily  have  been  lost  if  early 
attention  had  been  given  to  these  deposits.  There  was  not  the 
slightest  indication  of  caries  upon  any  of  them,  and  it  is  safe  to 


Fig   4. 


conclude  that  had  the  patients  sought  and  obtained  proper  dental 
service  in  the  initial  stages  of  the  affection  the  teeth  might  have 
been  preserved  for  many  years  of  usefulness.  It  is  true  that  in 
these  particular  cases  the  patient  had  failed  to  apply  to  the  dentist 
in  time  to  accomplish  anything,  through  an  ignorance  of  the 
significance  of  the  deposits,  and  yet  there  would  seem  to  be 


Fig.  5. 


many  instances  where  the  neglect  is  not  entirely  traceable  to  the 
patient.  It  should  be  the  office  of  the  dentist  not  only  to  per- 
form operations  on  the  teeth,  but  to  so  educate  those  who  come 
under  his  charge  that  the  general  public  shall  be  made  familiar 
with  conditions  so  readily  understood  as  these,  and  so  mani- 
festly self-evident  when  attention  is  once  called  to  them. 


4  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

KINDS  OF  DEPOSITS 

Deposits  are  usually  classified  under  three  kinds,  salivary 
calculus,  serumal  calculus,  and  green  stain,  though  from  an  opera- 
tive point  of  view  the  latter  would  seem  to  be  widely  distinguish- 
able from  the  other  two.  It  is  not  a  deposit  of  appreciable  bulk, 
and  it  is  entirely  different  in  character,  both  as  regards  its  deleteri- 
ous effects  and  the  methods  to  be  employed  in  its  removal.  Nor 
would  it  seem  to  be  altogether  appropriate  to  limit  the  term  to 
"green"  stain.  There  are  other  stains  on  the  teeth  besides  those 
of  a  green  color,  and  they  should  not  be  ignored  in  considering 
the  subject. 

Salivary  Calculus 

This,  as  its  name  implies,  is  chiefly  a  deposit  from  the  saliva. 
The  solid  constituents  of  this  secretion,  which  are  normally  held 
in  solution  during  its  progress  from  the  gland  to  the  mouth,  be- 
come so  affected  by  the  change  of  environment  on  entering  the 
oral  cavity  as  to  be  precipitated  in  the  form  of  calculus  on  the 
teeth.  This  being  true,  we  should  naturally  expect  to  find  the 
most  extensive  deposits  upon  the  surfaces  of  the  teeth  lying 
nearest  to  the  openings  of  the  salivary  ducts,  a  fact  borne  out 
by  clinical  observation.  The  usual  points  of  initial  deposit  of 
salivary  calculus  are  upon  the  lingual  surfaces  of  the  lower  incisors, 
opposite  the  openings  of  the  ducts  from  the  sublingual  and  sub- 
maxillary glands,  and  upon  the  buccal  surfaces  of  the  upper 
molars,  which  are  copiously  bathed  in  the  parotid  saliva.  This 
must  not  imply  that  these  are  the  only  surfaces  subject  to  the 
deposition  of  salivary  calculus.  There  is  no  surface  of  any  tooth 
exposed  to  the  fluids  of  the  mouth  which  may  not  accumulate 
this  deposit,  provided  there  is  an  absence  of  friction  on  that 
surface. 

The  full  function  of  mastication  would  seem  to  be  one  of  the 
most  effectual  natural  processes  in  limiting  the  deposition  of 
salivary  calculus,  it  being  plainly  evident  to  an  observant  operator 
the  moment  he  looks  in  a  mouth  where  mastication  is  confined 
to  one  side.  It  will  invariably  be  found  that  the  teeth  on  the 
unused  side  will  present  an  altogether  neglected  appearance,  and 
if  there  is  a  predisposition  to  the  formation  of  calculus  they  wiU 
be  almost  completely  covered  with  it,  even  over  the  occlusal 
surfaces.     A  striking  object-lesson  may  be  given  patients  as  to 


DEPOSITS    ON   THE    TEETH  5 

the  necessity  of  keeping  the  teeth  in  active  and  uniform  service 
by  calHng  attention  to  the  difference  in  appearance  of  the  teeth 
on  the  two  sides,  and  impressing  them  with  the  fact  that  where- 
ever,  for  any  reason,  thorough  mastication  is  impractica?jle  the 
deficiency  should  be  supphed  by  substituting  artificial  friction 
with  the  tooth-brush.  The  demand  for  friction  relates  as  well  to 
the  gums  as  to  the  teeth,  it  being  very  exceptional  to  find  a 
healthy  condition  of  the  gums  in  any  locality  not  subjected  to 
full  functional  use. 

This  question  of  giving  the  teeth  and  gums  adequate  employ- 
ment should  be  carefully  studied  by  operators,  and  its  necessity 
forced  upon  the  attention  of  patients.  It  is  the  keynote  of  health 
in  the  mouth,  as  elsewhere  in  the  human  body,  and  it  should  be 
the  prime  function  of  the  dentist  to  keep  the  oral  tissues  healthy. 
It  is  infinitely  a  higher  aim  to  prevent  disease  than  to  cure  it, 
and  if  dentists  take  this  matter  seriously  to  heart  they  can  ac- 
complish much  in  this  direction.  A  critical  study  should  be 
made  of  the  conditions  present  in  every  mouth  coming  under  the 
operator's  attention,  and  a  careful  note  made  of  the  various 
landmarks  of  neglect.  The  results  of  this  neglect  must  invariably 
be  pointed  out  to  the  patient,  and  an  impression  made  in  such  a 
manner  that  it  cannot  be  ignored.  If  the  dentist  thereby  fails 
to  enlist  the  co-operation  of  his  patient,  it  is  only  common  justice 
to  at  once  absolve  himself  from  responsibility  for  the  ultimate 
saving  of  the  teeth.  This  will  usually  bring  the  patient  to  a 
proper  realization  of  the  true  relation  existing  between  operator 
and  patient,  and  will  at  least  establish  an  intelligent  understand- 
ing between  them. 

In  character  salivary  calculus  may  vary  from  a  soft  granular 
mass,  easily  removed  and  disintegrated  with  an  instrument,  to  a 
hard,  dense,  and  almost  flint-like  consistence.  This  difference 
in  density  relates  chiefly  to  the  rapidity  with  which  it  is  formed 
and  the  length  of  time  it  is  allowed  to  remain  in  the  mouth. 
When  it  is  rapidly  deposited  and  of  recent  formation  it  is  com- 
paratively soft,  but  seems  to  grow  progressively  harder  if  left 
undisturbed.  The  color  also  varies  materially  in  different  speci- 
mens, from  a  yellowish  gray  to  a  black,  the  former  usually  being 
associated  with  rapid  and  recent  formations,  while  the  latter  is 
ordinarily  confined  to  cases  of  long  standing.  In  some  mouths 
the  yellowish  gray  remains  almost  indefinitely,  so  that  the  ques- 
tion of  color  is  not  entirely  one  of  age;  and  yet  in  specimens  of 


6  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

extensive  accumulation,  such  as  those  illustrated,  it  will  usually 
be  found  that  the  portion  nearest  the  tooth,  and  also  that  immedi- 
ately overlying  the  gum-tissue,  and  which  accordingly  has  been 
longest  in  place,  is  much  darker  than  that  more  recently  formed 
upon  the  surface. 

The  present  reference  to  color  relates  to  a  staining  of  the  calcu- 
lus itself,  and  not  to  a  surface  deposit  of  black  such  as  is  commonly 
found  in  the  mouths  of  smokers.  The  latter  is  a  characteristic 
jet-black  discoloration,  unmistakably  from  tobacco  smoke,  while 
the  former  is  less  intensely  black,  with  sometimes  a  greenish 
tinge — especially  where  it  has  been  long  in  contact  with  the 
gum — and  its  source  is  not  so  apparent. 

Serumal  Calculus 

This  deposit  is  distinguishable  from  salivary  calculus  in  several 
particulars,  but  chiefly  in  its  initial  point  of  location  on  the  tooth. 
Salivary  calculus  finds  its  lodgment  on  that  portion  of  the  tooth 
which  is  bathed  in  saliva,  and  therefore  becomes  adherent  to  the 
crown  or  neck  of  the  tooth,  the  part  not  covered  by  the  gum. 
It  may  advance  and  force  the  gum  and  adjacent  tissues  back  so 
as  to  follow  the  root  to  the  apex,  as  in  Fig.  1;  and  yet  it  begins 
not  under  the  gum,  but  crownwise  of  it.  Serumal  calculus,  on 
the  contrary,  attaches  itself  to  the  root  of  the  tooth,  or  to  that 
portion  of  the  neck  which  is  covered  by  the  gum.  The  source  of 
this  deposit  is  therefore  different  from  salivary  calculus,  and,  as 
its  name  implies,  it  is  supposed  to  be  from  the  serum  of  the 
blood.  In  fact,  it  has  sometimes  on  this  account  been  termed 
sanguinary  calculus,  though  it  would  appear  that  there  are  certain 
formations  of  this  deposit  which  cannot  well  be  considered  as 
coming  directly  from  the  blood.  In  chronic  alveolar  abscess 
we  often  find  upon  the  apex  of  a  root  which  has  been  for  some 
time  constantly  bathed  in  pus  the  characteristic  serumal  deposit. 
But  it  at  least  may  safely  be  stated  that  serumal  calculus  is  a 
deposit  from  the  fluids  which  surround  the  root  of  the  tooth, 
while  salivary  calculus  is  deposited  frbm  the  fluids  in  contact 
with  the  crown. 

Another  point  of  distinction  between  the  two  is  found  in  the 
relative  bulk  of  the  deposit.  Salivary  calculus,  as  we  have  seen, 
may  assume  extensive  proportions,  while  serumal  calculus,  on 
account  of  its  environment,  is  restricted  in  growth,  and  is  usually 


DEPOSITS    ON   THE    TEETH  7 

found  in  the  form  of  small  nodules,  narrow  bands,  or  thin  scales 
(Figs.  6  and  7).  These  are  ordinarily  attached  quite  firmly  to 
the  surface  of  the  root,  and  require  considerable  force  to  dislodge 
them.  It  is  probable  that  the  irritation  produced  by  serumal 
calculus  under  the  gums  is  accountable  for  many  of  the  diseases 
to  be  found  in  the  surrounding  tissues,  and  which  frequently  lead 
to  loss  of  the  teeth,  it  being  impossible  to  conceive  of  gums  re- 
maining healthy  with  any  considerable  deposit  of  serumal  calculus 
under  them. 


Fig.  6.  Fig.  7. 

The  color  of  serumal  calculus  is  usually  darker  than  that  of 
salivary  calculus,  and  quite  commonly  has  a  greenish  tinge  run- 
ning through  it.  It  is  also  dense  in  structure,  and  is  probably 
formed  more  slowly  than  salivary  calculus.  It  may  be  found  in 
some  instances  deposited  in  a  thin  scale  along  the  side  of  the  root 
where  the  pericemental  membrane  has  been  lost,  or  it  may  occur 
as  small  nodules,  particularly^  at  the  apex  of  a  root,  as  the  result 
of  chronic  alveolar  abscess.  In  other  cases,  where  the  attachment 
of  the  pericemental  membrane  to  the  root  seems  perfect  from  the 
apex  to  near  the  alveolar  border,  but  where  the  free  margin  of  the 
gum  is  congested  and  puffed,  a  narrow  band  of  calculus  may  be 
found  encircling  the  neck  of  the  tooth  in  its  entire  circumference 
just  under  the  gum.  This  is  sometimes  so  near  the  margin  of  the 
gum  that  it  may  readily  be  seen  by  forcing  the  gum  back  with  a 
pledget  of  cotton.  In  any  pocket  formed  between  the  gum  and 
the  root  as  the  result  of  the  loss  of  that  portion  of  the  peri- 
cemental membrane,  we  may  ordinarily  expect  to  find  more  or 
less  of  a  deposit  of  serumal  calculus,  and  we  need  not  hope  to  see 
the  gum-tissue  overlying  this  become  healthy  so  long  as  the 
deposit  is  allowed  to  remain. 

Stains  on  the  Teeth 

These  may  present  themselves  in  varying  degrees  of  extent  and 
intensity,  and  in  varying  shades  of  color.     The  one  claiming  most 


8  PRINCIPLES    AND    PRACTICE    OF   FILLING    TEETH 

attention  from  the  profession  in  the  past  is  green  stain,  which 
seems  to  occur  with  the  greatest  frequency  on  the  labial  surfaces 
of  upper  incisors  in  young  patients.  It  may  also  be  found  in 
certain  instances  coating  the  entire  buccal  and  labial  surfaces  of 
all  of  the  teeth  in  adults,  though  this  is  comparatively  rare.  It 
would  appear  strange  that  so  much  prominence  has  been  given 
green  stain  to  the  almost  complete  ignoring  of  the  other  varieties. 
In  point  of  frequency  the  brownish  stains  are  more  prevalent, 
and  they  are  found  occurring  at  all  ages  and  upon  any  of  the  sur- 
faces of  the  teeth  not  subjected  to  considerable  friction,  but  it 
should  be  stated  in  this  connection  that  many  of  these  brown 
stains  will  exhibit  a  greenish  tinge  when  examined  with  a  mag- 
nifying glass. 

All  of  the  stains  seem  to  form  with  the  greatest  intensity  near 
the  gum-margin,  and  gradually  shade  away  toward  the  occlusal 
surface,  though  in  some  instances  they  constitute  a  more  or  less 
well-defined  concentric  band  near  the  gingival  line,  following  the 
curvature  of  the  gum,  and  including  the  lingual  as  well  as  the 
labial  surfaces.  There  is  a  wide  variation  in  the  degree  of  te- 
nacity with  which  these  stains  adhere  to  the  surfaces  of  the  teeth; 
in  some  instances  the  slightest  friction  being  all  that  is  necessary 
to  remove  them  completely,  while  in  others  they  seem  almost  part 
and  parcel  of  the  enamel  itself.  The  green  stains  are  usually 
more  adherent  than  the  brown,  and  in  cases  of  great  intensity  of 
stain  the  surface  of  the  enamel  is  disintegrated  and  roughened 
after  its  removal.  The  indications  in  every  instance  are  for  the 
perfect  polishing  away  of  all  such  stains  upon  the  teeth,  the  fact 
of  their  unsightliness  being  an  all-sufficient  reason  for  such  a  pro- 
cedure aside  from  the  somewhat  undetermined  point  as  to  their 
possible  deleterious  effect  upon  the  enamel. 

Another  variety  of  discoloration  upon  the  teeth  may  be  men- 
tioned as  being  distinct  from  the  green  and  brown  stains,  and  of  a 
character  entirely  peculiar  to  itself.  This  is  the  black  deposit 
caused  by  tobacco  smoke.  It  may  be  found  adherent  to  the 
teeth  of  smokers  much  the  same  as  the  other  stains,  except  that  it 
is  more  prevalent  on  the  lingual  surfaces,  and  it  has  more  appre- 
ciable bulk.  It  may  be  scraped  away  with  instruments,  leaving 
the  enamel  apparently  unaffected  under  it;  but  it  does  not  ac- 
cumulate like  salivary  calculus,  so  as  to  impinge  upon  the  gum 
or  cause  irritation  to  the  surrounding  parts.  In  instances  of  the 
long-continued  use  of  tobacco  the  structure  of  the  teeth  them- 


DEPOSITS    ON   THE    TEETH  9 

selves  may  become  so  stained  as  to  permanently  remain  so, 
particularly  where  the  enamel  is  gone  and  the  dentin  is  exposed 
to  the  smoke. 

REMOVAL  OF  DEPOSITS 

Removal  of  Salivary  Calculus 

There  are  two  principal  plans  of  manipulative  procedure  for  the 
removal  of  salivary  calculus,  the  push-cut  method  and  the  draw- 
cut  method,  each  having  different  forms  of  instruments  adapted 
to  its  use.  By  the  push-cut  method  the  blade  of  the  scaler  is 
brought  to  bear  upon  the  calculus  at  the  point  nearest  the  occlusal 
surface  of  the  tooth,  and  the  mass  dislodged  by  forcing  the  scaler 
between  the  calculus  and  the  enamel  in  the  direction  of  the  root. 
By  the  draw-cut  method  the  scaler  is  placed  rootwise  of  the  de- 
posit, and  force  applied  by  pulling  toward  the  occlusal  surface. 
Each  method  has  its  advocates  in  the  profession,  and  each  is 
applicable  to  certain  conditions,  the  best  practice  probably  being 
to  use  them  interchangeably,  as  circumstances  suggest.  The 
limitations  of  the  draw-cut  method  relate  to  the  fact  that  to  force 
an  instrument  of  sufficient  size  for  the  removal  of  salivary 
calculus  far  enough  rootwise  to  seize  the  deposit  frequently  in- 
volves considerable  impingement  on  the  gum,  with  consequent 
laceration;  while  by  the  skillful  use  of  the  push-cut  instrument 
the  deposit  may  often  be  forced  away  without  touching  the  gum 
at  all.  On  the  other  hand,  the  push-cut  method  invites  a  certain 
danger  which  is  never  present  with  the  draw-cut.  The  applica- 
tion of  force  directly  toward  the  gum  carries  with  it  the  constant 
possibility  of  the  instrument  slipping  and  wounding  the  gum, 
while  a  slip  of  the  draw-cut  instrument  is  comparatively  harmless. 
The  element  of  apprehension  on  the  part  of  the  patient  when  the 
push-cut  is  being  used  is  sometimes  a  menace  which  invites 
accidents  from  the  patient  flinching  on  the  application  of  force, 
thus  causing  the  instrument  to  glide  into  the  gum.  To  avoid 
accidents  of  this  nature,  and  to  carry  assurance  to  the  mind  of 
the  patient,  it  is  always  necessary  before  applying  any  force 
with  the  scaler  to  so  guard  the  hand  of  the  operator  against  undue 
movement  that  the  instrument,  in  case  it  does  slip,  will  not  be 
carried  into  the  gum.  This  can  be  done  by  bracing  the  unused 
fingers — the  ones  not  grasping  the  scaler — firmly  against  the 
occlusal  surfaces  of  the  teeth  before  applying  the  scaler  to  the 
deposit.     By  this  means  a  perfect  control  may  be  maintained 


10  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

over  the  instrument,  and  a  sense  of  security  imparted  to  the 
patient,  which  usually  results  in  a  reasonable  degree  of  confidence 
during  the  operation.  This  matter  of  creating  confidence  on  the 
part  of  the  patient  is  an  important  element  in  conducting  a 
successful  practice  in  all  lines  of  procedure,  and  the  operator 
should  study  the  manipulation  of  instruments  to  this  end.  The 
cardinal  principles  in  operating  should  be  precision  of  methods, 
firmness  of  control,  and  delicacy  of  execution.  Patients  are 
more  susceptible  to  impressions  made  upon  them  through  ma- 
nipulative procedure  than  the  average  operator  would  seem  to 
conceive  of.  They  are  quick  to  recognize  superior  skill  in  an 
operator  by  reason  of  his  mastery  of  instruments  and  the  apparent 
intelligence  with  which  he  approaches  his  work,  and  there  are  few 
operations  in  dentistry  calling  for  a  more  diversified  order  of  skill 
than  the  successful  removal  of  calculus  from  the  teeth. 

The  cases  are  so  varied  in  their  nature,  both  as  regards  the 
extent  and  location  of  the  deposit  and  also  the  character  of  the  teeth 
and  their  position  in  the  arch,  that  it  may  almost  be  said  that 
each  case  constitutes  a  law  unto  itself,  and  must  be  approached 
in  accordance  with  its  individual  requirements.  And  yet  it  would 
seem  desirable  to  formulate  so  far  as  possible  definite  rules  of 
procedure  in  this  as  in  all  other  operations  on  the  teeth,  though 
the  fact  must  constantly  be  borne  in  mind  that  in  any  formulation 
of  this  nature  the  element  of  personal  equation  must  necessarily 
enter  conspicuously  into  it  and  largely  influence  its  details.  No 
two  men  need  be  expected  to  approach  this  work  in  precisely  the 
same  way,  though  each  should  at  least  study  out  some  systematic 
order  of  procedure  for  his  own  guidance,  so  as  to  accomplish  the 
result  in  an  orderly  sequence,  rather  than  by  haphazard  and  slip- 
shod methods.  Lack  of  system  in  the  performance  of  our  work 
has  been  one  of  our  chief  limitations  as  operators,  and  it  is  account- 
able for  a  grievous  waste  of  time  both  to  practitioner  and  patient. 

The  methods  here  suggested  are  not  applicable  to  all  cases,  nor 
will  they  probably  appeal  to  all  operators;  but  it  is  confidently 
hoped  that  they  may  at  least  prove  helpful  to  those  who  in  the 
past  have  not  thought  it  necessary  to  employ  any  particular 
method  in  these  operations. 

Instruments  for  the  Removal  of  Calculus 

The  instruments  here  illustrated  are  largely  adaptations  from 
or  modifications  of  the  forms  long  since  introduced  to  the  profes- 


DEPOSITS    ON   THE    TEETH 


11 


sion  by  various  operators.  Fig.  8  is  a  somewhat  sickle-shaped 
contra-angle  instrument,  having  three  sides  for  cutting.  It  may 
therefore  be  used  interchangeably  as  a  push-cut  or  draw-cut 
instrument,  though  the  sharpest  or  most  acute  edge  being  along 
the  extremity  of  the  instrument  gives  it  greater  efficiency  as  a 
push-cut  than  as  a  draw-cut.  Its  uses  will  be  indicated  hereafter. 
Fig.  9  is  an  ordinary  direct  push-cut  scaler,  with  the  curvature 
somewhat  nearer  the  cutting-edge  than  usual;  while  Fig.  10  is  a 
long,  slender,  delicate  instrument  for  reaching  places  inaccessible 
to  Fig.  9.     Figs.  11,  12,  13,  and  14  are  hooked  instruments  of 


I — »  diP 


Fig.  8.  Fig.  9.  Fig.  10.  Fig.  11.  Fig.  12.  Fig.  13.  Fig.  14.  Fig.  15.  Fig.  16.  Fig.  17.  Fig.  18. 


varying  forms  for  draw-cut  work  along  the  roots  of  teeth  in 
pockets  under  the  gum,  the  two  former  being  from  the  Mawhin- 
ney  set.  One  precaution  should  be  taken  with  all  instruments 
used  for  this  purpose.  Ordinarily  the  back  of  the  scaler — 
the  side  coming  in  contact  with  the  gum  in  passing  between 
it  and  the  root — is  left  with  sharp  angles  and  corners,  which 
inflict  unnecessary  discomfort  on  the  patient  by  lacerating  the 
gum.  These  angles  should  be  rounded  off,  so  as  to  leave  a 
smooth  back  to  the  instrument,  which  may  be  insinuated  under 
the  gum  and  along  the  root  without  serious  disturbance  to  the 
patient.  Fig.  15  is  merely  a  short-bladed  hoe  excavator,  while 
Fig.  16  is  a  delicate  hatchet  excavator,  the  uses  for  which  will 
be  considered  later.  Fig.  17  is  a  curved  wide  push-cut  scaler 
for  passing  over  the  surfaces  of  teeth  where  the  bulk  of  the  deposit 
has  already  been  removed,  and  scraping  off  any  small  particles 
that  may  have  been  left.     Fig.  18  is  a  long-reach  push-cut  scaler 


12  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

for  approaching  localities  in  special  cases  inaccessible  to  the 
ordinary  instruments. 

Technique  of  the  Operation 

In  the  examination  for  calculus  on  the  teeth  probably  nine 
out  of  ten  operators  will  instinctively  place  the  mouth-mirror 
between  the  tip  of  the  tongue  and  the  lower  incisors,  and  reflect 
the  light  upon  the  lingual  surfaces  of  these  teeth.  It  is  there- 
fore natural  that  the  removal  of  the  deposits  should  begin  at 
this  point,  and  there  is  also  another  minor  reason  why  it  is  well 
to  start  where  there  is  considerable  material  to  be  removed.  It 
makes  an  instantaneous  impression  on  the  mind  of  the  patient 
as  to  the  extent  of  the  deposit  present,  and  arouses  an  interest 
in  the  work  which  nothing  else  will.  It  is  seldom  that  a  patient 
realizes  just  how  much  calculus  there  is  upon  the  teeth,  due  to 
its  gradual  formation  and  the  fact  that  the  tongue  becomes 
accustomed  to  its  presence.  But  if,  on  the  first  introduction 
of  the  scaler,  several  large  pieces  are  flaked  off  and  allowed  to 
fall  into  the  floor  of  the  mouth,  the  patient  is  startled  into  a 
realization  of  what  has  been  going  on,  and  is  impressed  with  the 
importance  of  proper  attention  to  the  matter  in  the  future.  The 
same  impression  never  seems  possible  later  on  in  the  operation 
if  the  large  masses  are  left  till  the  last. 

For  the  removal  of  salivary  calculus  from  the  lingual  surfaces 
of  the  lower  incisors  in  ordinary  cases  the  scaler  illustrated  in 
Fig.  8  is  admirably  adapted.  (It  need  not  here  be  urged  that 
all  scalers  should  be  keenly  sharp  in  whatever  location  they  are 
used.)  With  the  mouth-mirror  in  the  left  hand,  and  held  in 
such  a  position  that  the  tongue  is  kept  well  away  from  the  lower 
incisors  and  the  light  thrown  upon  the  deposit,  the  first  movement 
of  the  operating  hand  should  be  to  firmly  brace  the  end  of  the 
third  finger  against  the  occlusal  surfaces  of  the  adjacent  teeth 
in  such  a  manner  that  the  patient  must  at  once  realize  that  the 
operator  has  complete  control  of  the  instrument  against  slipping. 
This  accomplished,  rapid  work  is  possible.  A  push-cut  should 
be  used  along  the  disto-lingual  surface  of  the  right  lower  lateral, 
and  the  deposit  dislodged.  Immediately  this  is  done  the  point  of 
the  instrument  should  be  turned  rootwise  of  the  deposit  on  the 
mesio-lingual  surface  of  the  same  tooth,  and  a  draw-cut  given  to 
flake  it  off  along  that  surface.     Thus  with  two  movements,  one 


DEPOSITS    ON   THE    TEETH  13 

downward  and  the  other  upward,  the  large  bulk  of  calculus 
from  that 'tooth  has  been  dislodged  in  the  most  expeditious 
manner.  The  same  plan  should  be  followed  successively  with 
the  other  teeth  in  line  as  far  as  the  left  cuspid,  when  the  sickle- 
shaped  scaler  should  be  exchanged  for  Fig.  17.  With  this  the 
entire  lingual  surfaces  of  these  teeth  should  be  scraped  to  remove 
any  small  particles  of  deposit  which  may  have  been  left  by  the 
other  scaler,  and,  following  this,  attention  should  be  given  to 
the  lingual  surfaces  of  the  left  lower  bicuspids  and  molars. 
Beginning  with  the  mesio-lingual  aspect  of  the  first  bicuspid, 
these  surfaces  should  be  followed  in  regular  order  to  the  distal 
surface  of  the  left  lower  third  molar,  the  instruments  usually 
best  adapted  for  this  work  being  either  the  hoe  or  hatchet  forms. 
Figs.  15  and  16.  The  lingual  surfaces  of  all  of  the  lower  teeth 
to  the  left  of  the  right  cuspid  have  now  been  covered.  To 
reach  the  lingual  surfaces  of  the  right  cuspid  and  the  teeth  pos- 
terior to  it  the  operator  should  step  slightly  forw^ard  and  face  his 
patient,  so  as  to  look  along  these  teeth.  Then,  with  the  hatchet 
instrument  held  in  the  palm  and  the  thumb  braced  against  the 
teeth,  the  deposit  may  be  lifted  from  the  necks  very  expeditiously. 

After  the  lingual  surfaces  are  attended  to,  the  buccal  and  labial 
surfaces  may  ordinarily  be  reached  with  the  hatchet  instrument, 
using  the  pen  grasp  for  the  right  side  of  the  mouth  as  far  forward 
as  the  cuspid,  and  then  changing  to  the  palm  grasp  for  all  the 
teeth  to  the  left  of  that.  These  surfaces  should  be  followed  suc- 
cessively from  one  third  molar  to  the  other.  As  the  deposit  is 
being  lifted  from  the  labial  aspect  of  the  lower  incisors,  care 
should  be  taken  that  the  pieces  of  calculus  do  not  fly  into  the 
operator's  eyes.  The  force  is  necessarily  exerted  directly  toward 
the  operator,  and  the  particles  sometimes  snap  off  with  con- 
siderable momentum,  so  that  accidents  of  this  nature  are  not 
uncommon. 

When  large  masses  of  calculus  are  found  on  any  of  these  sur- 
faces, it  may  be  removed  with  the  push-cut  instruments,  Fig.  8 
or  17.  In  cases  of  great  recession  of  the  gum  and  extensive 
deposits  along  the  exposed  portion  of  the  roots,  particularly  if  the 
teeth  lean  in  toward  the  tongue,  so  that  they  stand  obliquely  in 
the  arch  and  are  very  long,  the  lingual  surfaces  can  only  be 
reached  to  good  advantage  with  an  instrument  like  Fig.  18.  In 
using  this  on  the  lower  incisors  or  right  cuspid,  bicuspid,  or  molars 
it  will  be  found  better  to  pass  to  the  left  side  of  the  patient  and 


14  PRINCIPLES    AND    PRACTICE    OP    FILLING    TEETH 

throw  the  Kght  down  into  this  secluded  locahty  with  the  mouth- 
mirror  in  the  left  hand.  The  right  hand,  grasping  the  scaler,  may 
pass  around  the  patient's  head  to  the  right  angle  of  the  mouth,  so 
that  the  end  of  the  third  finger  rests  on  the  occlusal  surfaces  of 
the  teeth  in  the  region  of  the  right  lower  cuspid  or  first  bicuspid. 
Braced  in  this  way,  effective  push-cutting  may  be  done  without 
impingement  of  the  gum. 

When  the  deposits  have  been  thoroughly  removed  from  the 
buccal,  labial,  and  lingual  surfaces  there  remain  only  the  proxi- 
mal surfaces  to  claim  attention.  For  this  work  where  there  has 
been  a  recession  of  the  gums,  and  the  deposit  is  accordingly  of  a 
salivary  formation,  the  push-cut  method  of  removal  is  by  far  the 
more  effective.  The  chair  should  be  raised  so  as  to  bring  the 
patient's  lower  teeth  well  opposite  the  operator,  and  a  direct  push- 
cut  exerted  from  labial  or  buccal  to  lingual  across  the  proximal 
surfaces.  For  this  work  the  scaler  Fig.  9  is  mostly  serviceable, 
though  in  some  cases  Fig.  10,  having  a  longer  reach  and  a  more 
dehcate  form,  is  applicable.  There  are  certain  instances  where 
this  method  of  push-cutting  from  labial  to  lingual  on  the  lower 
incisors  is  indicated  at  the  very  outset  of  the  operation,  before  any 
attempt  is  made  to  use  the  scaler  Fig.  8.  This  is  where  there  has 
been  much  recession  of  the  gums  and  the  interproximal  spaces  are 
wide  and  filled  with  calculus,  and  the  lingual  aspect  of  the  deposit 
presents  a  solid  phalanx  of  incrustation,  with  only  the  merest  line 
to  show  the  demarkation  between  the  different  teeth.  If  a  case 
of  this  kind  is  approached  from  the  labial  aspect  and  the  push-cut 
scaler  Fig.  9  is  forced  between  the  teeth  along  the  proximal  sur- 
faces toward  the  lingual,  the  large  masses  of  calculus  may  be 
tumbled  off  into  the  mouth  with  astonishing  ease  and  rapidity. 

The  operator  should  study  the  various  means  of  attacking  these 
deposits,  to  the  end  that  he  may  approach  the  work  in  the  dif- 
ferent phases  of  the  deposit  and  be  able  to  meet  each  case  in  the 
most  expeditious  manner. 

In  removing  salivary  calculus  from  the  upper  teeth  the  operator 
may  start  at  the  buccal  surface  of  either  third  molar.  The  work 
may  be  done  with  push-cut  scalers  if  the  deposit  is  bulky  or  with 
the  hatchet  and  hoe  forms  if  it  consists  only  of  a  narrow  ring  near 
the  gum.  For  the  proximal  surfaces  of  these  teeth  the  hatchet 
form  seems  best  adapted,  there  being  less  facility  for  employing 
the  ordinary  push-cut  instruments  than  with  the  lower  teeth.  It 
is  seldom  that  salivary  calculus  is  found  on  the  lingual  surfaces  of 


DEPOSITS    ON   THE    TEETH  15 

the  upper  teeth,  but  whenever  it  does  occur  it  can  best  be  removed 
with  the  hoe  form,  Fig.  15. 

Removal  of  Serumal  Calculus 

This  operation  is  one  really  requiring  the  utmost  delicacy  of 
touch  and  the  highest  degree  of  digital  perception.  All  of  the 
work  is  done  under  cover  of  the  gum,  where  the  operator  cannot 
see,  and  consequently  the  sense  of  feeling  is  the  only  guide.  This 
sense  must  be  highly  developed  if  the  operator  expects  to  attain 
anything  like  success  in  this  work.  He  must  be  able  to  distinguish 
accurately  by  the  impressions  conveyed  to  him  through  contact  of 
the  instrument  with  the  root  of  the  tooth  whether  he  is  touching 
calculus  or  cementum;  and  he  must  do  this  not  by  reason  of  the 
bulk  of  the  deposit,  but  from  the  nature  of  its  density.  There  is 
a  decided  difference  in  the  character  of  the  two  substances,  and  the 
practiced  operator  can  make  a  sharp  distinction  between  them. 
The  necessity  for  this  lies  in  the  fact  that  in  many  instances 
the  formation  is  limited  to  the  thinnest  possible  scale  along 
the  side  of  the  root,  sometimes  resting  in  a  concavity,  so  that  there 
is  no  appreciable  elevation  of  the  deposit  over  the  surface  of  the 
root.  In  such  cases  the  instrument  must  be  gently  raked  over 
the  surface,  and  the  line  of  demarkation  detected  between  the 
deposit  and  the  cementum.  This  may  be  done  by  carefully  not- 
ing the  difference  in  the  effect  upon  the  blade,  of  the  instrument 
when  encountering  the  two  materials,  cementum  and.  calculus. 
In  passing  over  cementum  a  sharp  instrument  will  readily  peel  up 
the  tissue  and  scrape  it  off,  much  as  one  may  scrape  a  bit  of  bone. 
It  has  a  dead,  comparatively  soft  consistence,  so  that  the  scaler 
"bites"  into  it  readily.  With  serumal  calculus  the  case  is  dif- 
ferent. The  scaler  encounters  a  hard,  flint-like  substance,  which 
gives  a  decided  resistance  to  the  instrument,  and  which  cannot 
be  scraped  to  lessen  its  bulk.  It  must  be  dislodged  en  masse  or 
not  at  all.  By  cautiously  feeling  along  the  root  the  expert  opera- 
tor is  thus  enabled  to  detect  the  slightest  flake  of  calculus  and  to 
remove  it. 

The  instruments  best  adapted  for  this  delicate  kind  of  work  are 
the  hooked  forms.  Figs.  11,  12,  13,  and  14.  They  may  be  insinu- 
ated up  under  the  gum  into  a  pocket  alongside  the  root,  and  thus 
scrape  it  free  from  deposits  with  a  draw-cut.  The  greatest 
patience  and  perseverance  are  necessary  for  the  thorough  removal 


16  PRINCIPLES    AND    PRACTICE    OP    FILLING    TEETH 

of  this  thin  scale-hke  deposit,  but  no  operator  does  his  full 
duty  to  his  patient  when  he  allows  it  to  remain. 

There  is  another  variety  of  deposit  coming  under  the  head  of 
serumal  which  is  distinct  from  the  scale-like  form,  and  is  fre- 
quently met  in  cases  where  there  is  no  appreciable  pocket.  This 
is  a  narrow  ring  encircling  the  root  just  under  the  free  margin  of 
the  gum,  dark  in  color,  dense  in  structure,  and  well  defined  in 
outline.  The  only  indication  of  its  presence  is  a  slightly  puffed 
and  congested  condition  of  the  gum  lying  over  it,  and  in  some 
instances  even  this  is  not  very  apparent  until  the  deposit  assumes 
appreciable  size.  It  cannot  be  seen  by  the  operator  without 
pressing  the  gum  back  from  the  neck  of  the  tooth,  but  it  may  be 
felt  with  a  fine  explorer.  It  is  often  present  on  the  proximal 
surfaces  without  forming  on  the  others,  and  it  seems  to  work  its 
greatest  injury  between  the  teeth.  If  allowed  to  go  unchecked 
it  results  in  a  detachment  of  the  gum  from  the  root  in  the  inter- 
proximal space,  and  a  general  impairment  and  puffing  of  the 
gum-festoons. 

The  removal  of  this  band  of  calculus  is  usually  best  accom- 
pUshed  on  the  lower  jaw  by  delicate  push-cut  scalers,  and  the 
work  is  greatly  facilitated  if  the  operator  will  pack  the  interproxi- 
mal spaces  in  advance  with  smaU  pellets  of  cotton  to  force  back 
the  gum,  so  as  to  expose  the  deposit.  The  cotton  requires  to  be 
in  place  only  a  few  minutes,  and  on  its  removal  the  scaler  must  be 
conveniently  at  hand  in  order  to  accomplish  the  work  before  the 
gum  creeps  back  over  the  deposit.  A  ready  method  of  proce- 
dure is  to  force  cotton  into  two  or  three  spaces  and  keep  that 
number  in  advance  of  the  operation,  so  that  by  the  time  each 
space  is  reached  the  gum  will  be  well  out  of  the  way.  In  this 
manner  the  calculus  can  ordinarily  be  seen  distinctly,  and  re- 
moved more  expeditiously  than  if  it  were  all  done  solely  by  the 
sense  of  touch.  For  the  upper  teeth  the  delicate  hatchet  excava- 
tor will  usually  be  indicated  in  place  of  the  push-cut  instruments, 
and  in  some  localities,  particularly  along  the  lingual  surfaces,  the 
hoe  form  will  be  most  effective. 

The  surfaces  of  all  roots  where  serumal  calculus  has  found  at- 
tachment should  be  very  carefully  scraped  and  left  smooth,  so 
that  the  gum  may  resume  its  normal  position  and  tonicity.  If 
small  particles  of  the  deposit  are  overlooked  and  allowed  to  re- 
main they  not  only  irritate  the  gum,  but  they  invite  the  rede- 
position  of  fresh  calculus  so  that  the  relief  is  only  temporary. 


DEPOSITS    ON    THE    TEETH  17 

The  gum  need  not  be  expected  to  become  healthy  where  any 
appreciable  particles  of  the  deposit  are  left,  and  in  a  week  or  two 
after  the  operation  for  removal  it  is  frequently  possible  to  locate 
the  precise  points  at  which  flakes  of  calculus  have  been  overlooked, 
on  account  of  the  appearance  of  the  gums  at  these  places.  If  a 
purplish  or  congested  condition  of  the  gum  persists  at  certain 
points,  it  may  be  taken  as  an  almost  infallible  indication  that  a 
bit  of  serumal  calculus  is  lying  under  it.  These  facts  are  eloquent 
object-lessons  as  to  the  necessity  for  constant  vigilance  in  keeping 
the  teeth  free  from  deposits. 

Removal  of  Stains  from  the  Teeth 

After  salivary  calculus  has  been  removed  with  instruments,  it 
will  usually  be  found  that  the  surfaces  formerly  covered  by  the 
deposit  are  left  somewhat  roughened  and  in  need  of  polishing  to 


Fig.   19. 

prevent  a  ready  attachment  of  fresh  calculus,  while  the  surfaces 
extending  from  the  point  of  deposit  are  ordinarily  more  or  less 
stained  and  unsightly.  To  complete  the  operation  as  it  should  be, 
and  also  to  remove  stains  from  the  teeth  where  there  has  been  no 
salivary  calculus,  it  is  necessary  to  so  polish  the  surfaces  of  the 
teeth  by  friction  that  the  enamel  will  assume  a  white  and  glisten- 
ing appearance. 

This  is  best  accomplished  by  rotary  appliances  in  the  engine  in 
the  form  of  brushes,  rubber  cones,  or  moose-hide  points  carrying 
finely  pulverized  silex.  In  most  oflB.ces  pumice  is  used  for  re- 
moving stains,  but  silex  is  preferable  in  every  way.  Probably 
the  most  effective  method  in  ordinary  cases  is  to  use  the  small 
polishing  brushes  made  for  the  purpose.  Fig.  19,  though  there  a^ e 
occasionally  places  where  the  cones  or  points  may  reach  to  better 
advantage.  The  brushes  should  invariably  be  of  the  stiffer 
variety,  on  account  of  the  tendency  to  soften  from  the  moisture 


18  PRINCIPLES   AND    PRACTICE    OF    FILLING    TEETH 

after  a  few  revolutions  on  the  tooth.  If  the  brush  becomes  soft 
it  is  useless. 

The  manner  of  using  the  brush  is  to  place  its  end  against  the 
surface  to  be  polished,  and  as  the  engine  revolves  to  cause  gentle 
pressure.  The  degree  of  pressure  will  determine  the  area  of 
enamel  to  be  covered  by  the  brush  from  the  spreading  of  the 
bristles,  Fig.  19,  and  in  this  way  the  brush  may  be  made  to  con- 
form accurately  to  the  curvature  of  the  gum,  and  thus  polish  the 
enamel  close  to  the  gingival  line  without  lacerating  the  gum  or 
irritating  it.  All  of  the  exposed  surfaces  of  the  teeth  should  be 
included  in  the  polishing  till  the  last  vestige  of  stain  is  removed, 
except  in  those  cases  where  the  tooth-tissue  itself  is  discolored  from 
tobacco  or  other  causes.  This,  of  course,  cannot  be  polished  off, 
though  even  a  tooth  in  this  condition  should  be  made  as  smooth 
on  the  surface  as  possible  by  friction  of  the  brush. 

In  moistening  the  silex  for  the  removal  of  stains  it  is  well  to 
use  some  other  liquid  than  water.  Miller  found  that  the  peroxid 
of  hydrogen  had  a  solvent  effect  on  green  stain,  and  it  is  an 
admirable  cleansing  agent  in  a  general  way.  While  the  main  re- 
liance in  the  removal  of  these  stains  should  be  the  mechanical 
friction  of  the  silex,  yet  there  would  seem  to  be  no  objection  to 
employing  adjuncts  in  the  form  of  liquids  having  an  antiseptic  or 
disinfectant,  as  well  as  a  solvent,  action  such  as  this.  In  cases  of 
highly  congested  gums,  where  the  slightest  contact  of  the  brush 
causes .  profuse  bleeding,  it  may  be  well  to  use  with  the  silex 
some  one  of  the  astringent  mouth-washes  on  the  market  whose 
formulae  are  published  and  known  to  the  operator.  It  is  also  a 
relief  to  the  patient  after  a  sitting  for  the  removal  of  calculus, 
where  there  has  necessarily  been  considerable  wounding  of  the 
gums,  to  add  some  of  this  wash  to  the  water  used  for  rinsing  the 
mouth.  In  every  case  where  silex  has  been  employed  the  teeth 
and  gums  should  be  thoroughly  syringed  with  tepid  solutions  to 
remove  as  perfectly  as  possible  all  traces  of  the  silex,  which  is 
insoluble  in  the  mouth,  and  which  should  not  be  left  lodging  in 
any  quantity  around  the  gum-margins. 

Two  items  bearing  on  the  hygiene  of  this  operation  must  be 
mentioned;  not  because  they  are  not  patent  to  every  conscientious 
and  observant  operator,  but  because  there  seems  to  be  much 
laxity  in  these  minor  details  on  the  part  of  some  in  the  profession. 
No  polishing  brush  should  ever  be  used  under  any  possible  cir- 
cumstance in  more  than  one  mouth.     They  are  made  in  such 


DEPOSITS    ON    THE   TEETH  19 

quantities  by  the  manufacturers,  and  are  so  inexpensive,  that 
there  is  no  manner  of  excuse  for  so  gross  a  violation  of  personal 
and  professional  refinement.  Outside  of  the  question  of  convey- 
ing infection,  the  idea  must  be  sufficiently  revolting  to  make  more 
than  a  mere  mention  of  it  unnecessary.  The  moment  a  set  of 
teeth  is  polished  the  brush  used  should  at  once  be  discarded,  and 
a  fresh  one  placed  in  the  mandrel,  which  itself  should  be  cleaned 
and  sterilized  each  time  it  is  used.  The  other  item  relates  to 
mixing  the  silex.  The  same  mix  should  not  be  made  to  do 
service  for  more  than  one  individual  A  convenient  quantity 
should  be  prepared  in  a  small  glass  or  porcelain  dish  for  each 
patient,  and  the  dish  thoroughly  cleaned  after  using.  These 
simple  precautions  are  not  only  demanded  on  the  basis  of  pro- 
fessional integrity,  but  they  are  really  remunei-ative  in  the  way  of 
inviting  patronage  of  the  most  desirable  kind.  Patients  are  more 
observant  of  these  matters  than  is  generally  supposed,  and  they 
are  usually  appreciative  of  every  effort  which  insures  to  them 
cleanliness  and  protection. 

ORAL  PROPHYLAXIS 

In  recent  years  a  new  departure  has  been  introduced  into 
practice  called  "oral  prophylaxis."  In  its  essentials  it  consists 
not  only  in  the  removal  of  deposits  and  stains  as  just  outlined, 
but  in  the  careful  smoothing  and  polishing  of  all  roughened 
surfaces  of  the  teeth  whether  on  the  enamel  or  on  fillings  or  crowns ; 
and  the  performance  of  this  operation  by  the  dentist  as  frequently 
as  once  a  month.  The  term  "oral  prophylaxis"  was  given  to 
this  practice  on  the  theory  that  it  would  act  as  a  preventive  of 
caries  and  all  diseases  of  the  supporting  structures  of  the  teeth. 
The  chief  credit  for  the  introduction  of  this  practice  is  due  to 
Dr.  D.  D.  Smith  of  Philadelphia,  who  first  emphatically  called 
the  attention  of  the  profession  to  it.  Some  men  since  Dr. 
Smith's  articles  were  written  have  gone  to  greater  length  than 
he  did  in  their  advocacy  of  this  practice,  and  have  carried  it  to 
such  extremes  as  to  threaten  serious  injury  to  their  patients. 

There  is  much  good  in  the  method  if  practised  judiciously, 
and  much  harm  if  used  without  discrimination.  To  take  a  mouth 
which  has  been  neglected  and  in  which  deposits  have  been  per- 
mitted to  remain  on  the  teeth  and  irritate  the  gums,  and  to  go 
over  each  tooth  carefully  and  remove  every  vestige  of  deposit  and 


20  PRINCIPLES    AND    PRACTICE    OF   FILLING    TEETH 

then  polish  the  surfaces  of  the  teeth  till  they  glisten  almost  like 
glass  will  result  in  such  improvement  in  the  conditions  in  the 
mouth  as  to  make  any  operator  enthusiastic  in  his  advocacy  of 
the  practice.     It  is  good  judgment  to  do  this  in  such  cases. 

It  is  equally  bad  judgment  to  take  a  mouth  where  the  gums  are 
not  hypertrophied,  where  there  is  little  tendency  to  the  formation 
of  deposits  and  where  the  gingival  areas  of  the  teeth  are  inclined 
to  be  sensitive,  and  scrape  and  grind  and  polish  such  teeth  as  is 
so  frequently  done  in  the  blind  following  of  this  practice.  To 
use  anything  like  a  stone  or  sandpaper  strip  to  reduce  small 
inequalities  in  such  teeth  is  to  render  them  excruciatingly  sensi- 
tive and  make  the  patient  more  uncomfortable  than  before. 
Then  again  the  mania  for  smoothness  and  evenness  which  impels 
an  operator  to  grind  down  all  small  prominences  on  the  teeth — 
in  some  instances  even  going  so  far  as  to  grind  the  proximal 
surfaces  sufficiently  to  ruin  the  contact  points — is  reprehensible 
in  the  highest  degree.  This  is  not  prophylaxis;  it  is  vandalism. 
Discrimination  and  judgment  are  needed  in  this  work  else  it 
will  be  brought  into  disrepute.  The  thing  to  be  emphasized 
most  in  the  performance  of  this  operation  is  cleanliness.  De- 
posits are  not  cleanly  and  they  should  be  removed.  Stains 
are  not  cleanly.  Overhanging  margins  of  fillings  are  irritat- 
ing agents  and  lead  to  uncleanness.  In  fact,  any  roughened 
surface  tends  to  the  accumulation  of  deposits,  and  deposits  tend 
to  irritation  of  the  surrounding  structures  of  the  teeth.  The 
idea  is  to  clean  the  teeth,  and  keep  them  clean.  In  furtherance 
of  this  the  smoother  the  surfaces  of  enamel  are  made  the  more 
easily  are  the  teeth  kept  clean  after  the  operation.  Silex  will 
remove  stains  and  whiten  the  enamel,  but  in  order  to  put  the 
proper  glisten  on  the  tooth  surface  it  must  be  very  fine.  Even 
then  on  some  enamel  it  is  well  to  follow  the  silex  with  a  powder 
less  abrasive  such  as  finely  ground  whiting,  or  the  powder  known 
as  Carmi-lustro. 

Then  there  are  surfaces  on  the  teeth  where  the  brush  will  not 
reach,  notably  the  proximal  surfaces  leading  to  the  contact 
points.  These  should  be  gone  over  with  a  wooden  polisher  in 
the  hand  whittled  thin  and  carrying  moistened  silex.  An  ex- 
cellent instrument  for  holding  these  wooden  points  is  found  in 
Fig.  20,  devised  by  Dr.  D.  D.  Smith  and  manufacured  by  J.  W. 
Ivory.  In  some  instances  better  results  may  be  obtained  with 
a  thin  polishing  strip  than  with  a  wooden  point,  a  very  effective 


DEPOSITS    ON    THE    TEETH 


21 


one  being  the  Carmi-lustro  strip  made  in  Milwaukee,  Wis. 
This  strip  is  thin  and  very  tough,  and  it  is  loaded  with  a  good 
polishing  medium.  If  too  wide  for  the  case  in  hand 
the  strip  may  be  split  to  any  desired  width  without 
affecting  its  wearing  qualities.  The  proximal  sur- 
faces of  the  teeth  may  be  smoothed  and  polished 
perfectly  by  passing  these  strips  through  the  inter- 
proximal spaces  and  carrying  them  gently  under 
the  free  margin  of  the  gum.  If  used  with  judgrhent 
they  will  in  no  way  injure  the  gum  tissue.  In  case 
the  surfaces  are  very  rough  the  strip  may  be 
preceded  by  a  fine  cuttle  fish  finishing  strip  to 
wear  down  the  inequalities,  but  care  must  always 
be  exercised  not  to  cut  into  the  necks  of  the  teeth 
in  the  attempt  to  make  them  smooth.  Surfaces 
of  enamel  polished  in  this  way  will  be  more  readily 
kept  clean  by  the  brush  or  floss  than  otherwise, 
and  after  this  process  has  been  practised  a  few  times 
the  condition  of  the  gums — particularly  if  hyper- 
trophied  before — will  be  found  greatly  improved. 
In  fact,  the  practice  of  oral  prophylaxis  if  properly 
followed  will  minimize  the  danger  of  disease  of  the 
supporting  structures  of  the  teeth,  as  well  as  limit 
th-e  tendency  to  dental  decay. 

The  frequency  with  which  the  teeth  should  be 
gone  over  in  this  way  must  be  governed  by  the 
conditions  present.  There  is  a  great  variation  in 
different  mouths  in  the  tendency  to  the  formation 
of  calcareous  and  other  deposits,  and  to  the  growth 
of  micro-organic  gelatinous  plaques;  and  there  is 
also  much  variation  in  the  same  mouth  at  different 
times.  A  good  procedure  in  managing  the  average 
case  is  this:  If  there  are  extensive  deposits  and 
much  hypertrophy  of  the  gums  only  three  or  four 
teeth  should  be  included  in  the  scaling  process  at 
each  sitting.  The  reason  for  this  is  that  there  is 
danger  of  making  the  mouth  sore  if  too  many 
teeth  are  treated  at  once.  Then  again  if  there  are 
pus  pockets  around  the  teeth  an  unfortunate  reac- 
tion may  set  up  by  forcing  too  many  pus  micro-  F^"-  '■^^■ 
organisms  into  the  circulation  by  the  instrumentation.     Another 


22  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

sitting  may  be  given  in  from  three  to  six  days,  and  this 
continued  till  every  tooth  in  the  mouth  has  been  treated.  At 
each  sitting  all  of  the  teeth  should  be  gone  over  with  the  brush 
and  fine  silex,  to  the  end  that  the  enamel  surfaces  are  made 
more  and  more  satisfactory;  and  in  the  final  sittings  the 
polishing  with  fine  strips,  wooden  points  and  whiting  should  be 
completed.  In  some  instances  the  silex  and  polishing-powder 
may  be  used  in  rubber  cups  made  for  this  purpose,  or  with 
moose  hide  wheels  in  the  engine.  After  the  mouth  is  placed  in  a 
satisfactory  condition  an  appointment  should  be  made  for  an 
examination  in  a  month,  and  subsequently  the  case  should  be 
seen  at  such  intervals  as  are  necessitated  by  the  existing  con- 
ditions. Much  will  depend  on  the  care  given  the  teeth  in  the 
intervals  by  the  patient — a  subject  to  be  considered  shortly. 

This  is  not  intended  as  a  dissertation  on  the  treatment  of 
pyorrhea  alveolaris,  though  it  may  be  said  in  passing  that  if 
the  practice  here  outlined  is  followed  faithfully  in  every  mouth 
there  will  be  little  need  for  treating  pyorrhea.  Prevention 
should  be  the  keynote  of  our  endeavors  in  this,  as  in  every  other 
line  of  practice,  and  if  teeth  are  taken  in  time  and  properly 
cared  for  these  diseases  may  be  prevented. 

Instructions  to  Patients  as  to  the  Care  of  the  Teeth 

The  dentist  has  done  much  less  than  his  whole  duty  if  he  con- 
tents himself  with  the  mere  performance  of  the  operation  of  clean- 
ing the  teeth,  and  fails  to  so  instruct  his  patient  that  they  may 
thereafter  be  kept  clean.  Comparatively  few  individuals  really 
know  how  best  to  care  for  the  teeth,  and  it  should  be  the  office  of 
the  dentist  to  so  educate  those  coming  under  his  charge  that  the 
result  will  be  a  more  general  enlightenment  on  this  important  sub- 
ject. An  opportune  moment  for  making  an  appreciable  impres- 
sion is  just  at  the  conclusion  of  a  sitting  for  the  removal  of  calculus 
and  stain,  when  the  patient's  mind  will  most  likely  be  in  a  recep- 
tive mood  on  the  subject. 

The  technique  of  brushing  the  teeth  should  be  explained  so 
that  the  patient  may  learn  how  to  reach  all  of  the  surfaces  with 
the  brush,  and  to  impart  the  requisite  friction  to  the  gums  and 
teeth  without  doing  injury.  The  ill-advised  cross-brushing  of 
teeth  with  gritty  powders  has  undoubtedly  done  much  harm  in 
forcing  the  gum  away  from  the  necks  of  the  teeth,  so  as  to  admit 


DEPOSITS    ON   THE    TEETH  23 

of  a  groove  being  cut  by  the  brush  just  rootwise  of  the  enamel. 
Cross-brushing  is  not  entirely  unavoidable  in  a  thorough  cleansing 
of  the  teeth,  nor  is  it  at  all  injurious  if  used  with  judgment,  but 
the  patient  should  be  taught  the  danger  of  an  indiscriminate 
sawing  against  the  necks  of  the  teeth  with  a  stiff  brush  loaded 
with  a  gritty  powder  or  paste.  The  general  plan  of  brushing  the 
teeth  should  be  to  produce  a  sort  of  rotary  movement  with  the 
brush,  so  as  to  bring  the  bristles  against  the  lower  gums  and  teeth 
on  the  upward  motion  and  against  the  upper  ones  on  the  down- 
ward motion.  This  cannot  be  done  with  anything  like  precision 
on  all  of  the  teeth,  but  it  should  be  the  general  aim  with  the  idea 
ever  in  mind  that  the  gums  require  friction  as  well  as  the  teeth, 
and  that  they  must  be  brushed  against  the  necks  of  the  teeth 
instead  of  away  from  them.  In  cases  where  the  patient  com- 
plains that  the  gums  are  too  sensitive  to  admit  of  proper  brushing 
of} the  teeth,  they  should  be  subjected  to  a  thorough  system  of 
massage  with  the  fingers  three  or  four  times  a  day  till  they 
become  sufficiently  hard  to  comfortably  tolerate  any  ordinary 
brushing. 

As  to  the  frequency  with  which  teeth  must  be  brushed  by  the 
patient  to  keep  them  well  cleaned,  no  definite  rule  can  be  given 
on  account  of  the  variation  in  the  different  mouths.  In  one  indi- 
vidual the  teeth  may  be  kept  in  admirable  condition  with  one-half 
the  care  that  would  be  necessary  for  another,  and  even  in  the 
same  individual  as  has  been  stated  there  is  considerable  variation 
at  different  periods  in  the  tendency  to  the  accumulation  of  de- 
posits. Patients  must  therefore  be  requested  to  study  the  matter 
on  their  own  behalf  till  they  learn  with  some  degree  of  accuracy 
just  how  much  care  is  necessary  to  keep  the  teeth  bright  and 
clean. 

The  use  of  floss  for  passing  between  the  teeth  and  removing 
any  particles  which  may  be  found  lodging  where  the  brush  will 
not  reach  is  an  admirable  practice,  provided  the  patient  will  use  it 
judiciously  and  without  working  injury  to  the  gum.  The  great 
danger,  as  used  by  most  individuals,  lies  in  the  fact  that  in  passing 
it  between  the  teeth  it  is  inclined  to  snap  as  it  passes  the  contact 
points  and  come  down  forcibly  upon  the  festoon  of  gum.  This 
may  in  time  injure  the  gum  and  force  it  back  in  the  interproxi- 
mal space,  leaving  the  space  imperfectly  filled  with  tissue.  When- 
ever floss  is  used  it  should  be  most  carefully  guarded  as  it  is  pass- 
ing the  contact  points  and  prevented  from  impingeing  on  the  gum , 


24  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

and  unless  the  patient  can  gain  control  of  it  in  this  way  it  had 
better  not  be  used. 

One  feature  in  the  care  of  the  teeth  by  the  patient  must  not  be 
overlooked.  This  relates  to  the  use  of  toothpicks,  which,  if 
properly  employed  and  of  suitable  form,  may  be  used  to  ad- 
vantage for  the  dislodgment  of  certain  kinds  of  food-material 
from  between  the  teeth,  but  which  if  used  as  they  too  commonly 
are  may  result  in  great  injury  to  the  gums.  The  large  blunt 
wooden  toothpicks  so  extensively  provided  for  the  patrons  of 
public  eating-houses  are  especially  calculated  to  work  irreparable 
injury  if  persisted  in.  Aside  from  the  rough  nature  of  the  -wood 
and  the  sharp  corners  and  blunt  ends,  all  of  which  tend  to  irritate 
the  gums,  the  very  bulk  of  the  pick  is  such  as  to  finally  force  all 
of  the  gum  out  of  the  interproximal  space  and  furnish  a  receptacle 
between  the  teeth  for  the  constant  collection  of  food.  Dentists 
should  invariably  discourage  the  use  of  such  destructive  agents  as 
these.  Whenever  a  toothpick  is  indicated  at  all,  it  should  be  of 
the  very  thinnest,  smoothest,  and  most  flexible  nature.  Prob- 
ably the  best  toothpick  is  the  quill,  which  can  be  scraped  with  a 
knife  to  any  degree  of  fineness  and  pliability.  The  constant 
habit  of  picking  the  teeth,  as  a  habit,  should  be  discouraged,  and 
the  custom  limited  to  the  mere  removal  of  particles  of  food  which 
may  find  lodgment  between  the  teeth. 


CHAPTER  II 
DENTAL  CARIES 

It  is  scarcely  within  the  province  of  this  work  to  enter  minutely 
into  the  etiology  of  dental  caries,  and  yet  a  few  observations 
bearing  on  the  subject  from  an  operative  point  of  view  would 
seem  to  be  eminently  in  order.  Dental  caries  has  been  accounted 
one  of  the  most  prevalent  of  all  human  diseases,  and  one  of  the 
most  persistent  through  life,  in  view  of  which  it  would  appear 
on  the  face  of  it  a  very  discouraging  task  to  attempt  to  combat 
this  affection.  In  fact,  there  are  many  men  in  the  profession 
who  apparently  give  themselves  over  very  easily  to  this  idea, 
and  consign  the  natural  teeth  to  the  grasp  of  the  forceps  with  a 
resignation  which  borders  closely  on  an  assumption  of  the  in- 
evitable. This  ready  yielding  on  their  part  has  its  influence 
on  the  patient,  and  an  unfortunate  impression  is  thus  allowed  to 
go  out  to  the  effect  that  in  many  cases  it  is  quite  impossible  to 
save  the  teeth,  and  therefore  waste  energy  to  make  the  attempt. 
This  teaching  is  wrong  in  the  highest  degree,  and  the  profession 
has  much  to  answer  for  if  it  fails  to  inform  itself  in  the  most 
intimate  manner  on  the  true  relation  of  this  disease  to  the  human 
economy,  and  on  the  best  means  of  securing  its  control. 

A  close  study  of  the  manifestations  of  dental  caries  will  reveal 
the  fact  that  while  it  may  be  considered  a  very  persistent  disease, 
it  is  seldom  the  case  that  it  is  continuously  so  either  in  relation 
to  its  initial  appearance  or  the  degree  of  its  severity.  Some  of 
the  rnost  discouraging  cases  that  come  under  the  attention  of  the 
practitioner  will  be  found,  if  carefully  studied,  to  experience 
periods  of  immunity  from  attack,  during  which  the  process  of 
decay  seems  for  the  time  suspended.  In  fact,  it  is  the  exception, 
rather  than  the  rule,  for  teeth  to  go  progressively  to  destruction 
from  caries  one  after  the  other  till  every  tooth  is  lost  without 
intervals  of  practical  cessation  of  activity  on  the  part  of  the  micro- 
organisms which  bring  about  decay,  even  where  no  attempt 
is  made  to  combat  the  disease.  Cases  are  frequently  noted  where 
a  number  of  teeth  in  a  mouth  have  been  lost  through  caries 

25 


26  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

while  the  remaining  teeth  present  themselves  years  afterward 
practically  free  from  caries,  the  disease  seemingly  becoming 
limited  with  the  loss  of  the  teeth  that  are  missing.  It  might  be 
thought  in  such  cases  that  there  was  something  in  the  structure 
of  the  remaining  teeth  which  accounted  for  their  escape  were 
it  not  for  the  fact  that  these  same  teeth  may  at  a  subsequent 
period,  without  any  appreciable  provocation,  take  on  an  active 
attack  of  caries  and  require  the  closest  attention  to  save  them. 

In  a  broad  view  of  the  whole  question  of  the  susceptibility  to  or 
immunity  from  caries,  it  seems  to  resolve  itself  down  to  the  fact 
that  in  some  mouths  the  conditions  are  such  that  the  micro- 
organism of  caries  cannot  work  effectively  upon  the  teeth,  while 
in  others  they  are  favorable  to  its  most  active  influence,  and  that 
in  the  same  mouth  there  are  periods  when  the  conditions  favor  the 
work  of  the  micro-organism,  and  others  when  they  interfere 
with  its  action.  Just  what  these  conditions  are  the  profession 
at  present  do  not  seem  to  be  able  to  determine.  Professor 
W.  D.  Miller  demonstrated  some  years  ago  that  caries  was 
brought  about  by  the  action  of  an  acid  produced  as  the  result 
of  micro-organic  growth  in  the  mouth,  and  Dr.  G.  V.  Black 
called  attention  to  the  fact  that  this  acid  must  be  formed  and 
allowed  to  act  immediately  at  the  point  where  the  decay  was  to 
begin.  (In  fact,  Robertson,  in  1828,  indicated  that  the  carious 
process  was  the  result  of  some  influence  acting  directly  on  the 
enamel  at  certain  points  where  the  cavities  were  to  occur,  his 
idea  being  that  this  influence  was  due  to  "decomposition.") 
It  was  therefore  seen  that  the  old  and  somewhat  prevalent  idea 
that  the  reaction  of  the  saliva  had  something  to  do  with  the 
progress  of  caries  must  be  abandoned,  so  far,  at  least,  as  any 
direct  action  on  the  tooth-tissue  was  concerned..  Saliva  in  the 
mouth  cannot  become  sufficiently  acid  to  penetrate  the  teeth 
in  the  way  we  find  decay  manifest  in  most  cases.  If  it  were  so 
sharply  acid  the  soft  tissues  could  not  tolerate  it,  and,  besides, 
if  it  was  the  saliva  which  did  the  work  we  should  find  the  entire 
exposed  surfaces  of  the  teeth  melted  down  instead  of  being  pene- 
trated at  certain  points.  It  remained  to  be  determined  how  any 
requisite  number  of  micro-organisms  could  remain  stationary  on 
certain  unsheltered  surfaces  of  the  teeth  where  decay  was  seen 
to  occur  for  a  sufficient  time  to  form  their  acid  and  dissolve  the 
enamel,  without  being  washed  away  by  the  fluids  of  the  mouth. 

It  is  found  in  the  cultivation  of  micro-organisms  that  there  are 


DENTAL    CARIES  27 

certain  forms  which  in  the  progress  of  their  development  form  a 
substance  alUed  in  physical  appearance  to  gelatin,  and  are  there- 
fore called  gelatin-forming  micro-organisms.  It  is  supposed 
that  to  this  class  the  micro-organisms  of  caries  belong,  and,  in 
pursuance  of  their  function,  they  produce  on  the  surface  of  the 
tooth  a  gelatinous  film,  under  cover  of  which  they  are  enabled 
to  work  their  destructive  processes  undisturbed.  This  film  is 
sufficiently  adherent  to  the  tooth  to  withstand  the  ordinary 
rinsing  of  fluids  in  the  mouth,  and  thus  we  see  decay  taking 
place  in  positions  where  the  micro-organism  itself  would  be  washed 
away  if  left  unprotected.  But  the  film  may  be  broken  up  and 
detached  by  any  appreciable  amount  of  friction,  such,  for  instance, 
as  the  friction  of  food  in  mastication  where  that  process  is  exercised 
to  its  fullest  functional  activity.  Accordingly,  we  may  look  for 
the  greatest  ravages  of  decay  in  surfaces  of  the  teeth  not  subject 
to  the  friction  of  food,  as  the  proximal  surfaces,  or  in  sheltered 
localities  formed  by  developmental  defects,  as  in  the  fissures  or 
pits  where  the  micro-organisms  may  work  unmolested,  and  this 
phenomenon  is  amply  demonstrated  in  clinical  observation. 

The  legitimate  office  of  the  tooth-brush,  the  dental  floss,  or  the 
toothpick  may  be  more  intelligently  comprehended  when  the 
character  and  significance  of  this  gelatinous  film  is  understood. 
If  that  film  can  be  kept  from  the  teeth  it  would  seem  that  we  have 
small  need  for  worry  over  the  problem  of  controlling  dental  caries, 
and  in  this  connection  our  advice  to  patients  as  to  the  proper 
time  to  brush  the  teeth  should  be  governed  largely  by  a  recogni- 
tion of  the  facility  with  which  this  film  may  form  under  favorable 
conditions.  If  we  find  a  mouth  where  decay  is  progressing 
rapidly,  showing  active  work  on  the  part  of  the  micro-organisms, 
we  should  advise  frequent  attention  to  the  teeth,  so  as  to  inter- 
fere as  largely  as  possible  with  the  formation  of  these  films. 
Brushing  the  teeth  three  times  a  day  under  these  conditions 
will  not  be  too  much,  but  the  time  of  all  others  when  it  is  necessary 
to  go  over  every  surface  carefully  with  brush,  pick,  or  floss  is 
just  before  retiring,  when  the  fluids  of  the  mouth  are  to  remain 
quiet  for  the  greatest  length  of  time  in  the  twenty-four  hours, 
and  the  micro-organisms  are  given  the  best  opportunity  for  work. 

As  has  been  intimated,  cleanliness  of  the  teeth  may  be  con- 
sidered an  important  adjunct  in  checking  the  inroads  of  the 
micro-organisms,  but  unless  it  is  faithfully  pursued,  and  the 
cleansing  is  of  sufficient  frequency,  it  will  not  be  found  wholly 


28  PRINCIPLES   AND    PRACTICE    OF    FILLING    TEETH 

eJEfective  in  preventing  caries  in  mouths  where  the  tendency  to  its 
development  is  favorable.  It  is  a  question  of  hours  instead  of 
days  when  these  micro-organisms  can  form  gelatin  and  produce 
acid,  and  a  mouth  may  be  cleansed  as  perfectly  as  possible  once 
in  twenty-four  hours  and  yet  give  the  micro-organisms  ample 
time  to  act  in  the  intervals,  provided  the  conditions  are  suitable 
to  their  progress. 

It  was  formerly  the  prevalent  idea  in  the  profession  that  the 
structure  of  the  teeth  had  much  to  do  with  the  liability  to  decay; 
that  teeth  which  were  found  to  be  extensively  attacked  must  be 
considered  of  poor  structure,  while  those  practically  free  from 
caries  were  accordingly  accounted  as  being  of  good  structure. 
The  investigations  of  Dr.  Black  into  the  physical  character  of  the 
teeth  proved  that  this  position  was  untenable;  that  there  was 
really  much  less  variation  in  the  structure  of  the  teeth  than  had 
been  supposed,  and  that  what  little  difference  did  exist  seemed 
to  have  almost  no  relation  to  the  liability  to  decay.  It  simply 
resolved  itself  down  to  a  question  of  environment.  If  teeth 
decayed  rapidly  in  a  mouth  it  was  because  the  conditions  in  that 
mouth  were  favorable  to  the  agencies  which  bring  about  decay, 
and  not  because  the  teeth  were  necessarily  of  poor  structure. 

That  conditions  exist  in  the  mouth  which  influence  this  matter 
for  good  or  ill  is  clearly  evident  from  a  clinical  study  of  cases. 
We  find  that  there  is  in  tl  e  same  individual  a  great  variation  at 
different  periods  in  the  tendency  to  caries,  and  since  we  have 
learned  that  the  tooth-tissue  is  not  so  fluctuating  in  its  character, 
and  does  not  grow  hard  and  soft  so  readily  as  was  formerly  sup- 
posed, we  must  look  to  changes  in  the  conditions  surrounding  the 
teeth  to  account  for  the  varying  manifestations  of  the  disease. 

A  close  study  of  cases  in  practice  will  reveal  some  rather 
marked  instances  of  periodical  susceptibility  and  immunity,  and 
the  history  of  these  cases  will  often  prove  not  only  of  the  greatest 
value,  but  also  a  source  of  the  utmost  satisfaction  and  encourage- 
ment. The  recital  at  this  point  of  a  single  case  from  practice  may 
serve  to  indicate  the  common  run  of  such  clinical  histories  where 
the  disease  is  followed  up  vigorously  by  the  dentist.  This  case 
seemed  a  desperate  one,  a  case  in  which,  under  ordinary  circum- 
stances, many  of  the  teeth  would  probably  have  been  lost  if  any 
half-hearted  methods  of  treatment  had  been  employed.  And  yet 
the  final  outcome  was  such  as  may  be  confidently  expected  in 
nine  cases  out  of  ten  where  the  dentist  is  in  earnest  with  his  work 


DENTAL    CARIES  29 

and  has  an  intelligent  conception  of  the  possibilities  of  an  ap- 
proaching immunity. 

The  patient  was  a  girl  of  eight  or  nine  when  brought  to  the 
dentist  by  her  parents,  and  the  first  permanent  molars  were 
already  affected.  From  this  time  forward  during  the  next  six 
or  seven  years  the  activity  of  the  carious  process  in  that  mouth 
was  appalling.  Teeth  would  decay  on  their  journey  through  the 
gums  in  eruption;  recurrences  of  caries  around  fillings  would 
take  place  with  discouraging  frequency,  and  new  cavities  would 
spring  up  seemingly  almost  in  a  night.  The  dentist  did  the  best 
he  could,  which  he  freely  acknowledges  was  not  very  good,  owing 
to  the  hypersensitiveness  of  the  dentin  wherever  decay  occurred. 
But  an  honest  effort  was  made  to  fight  back  the  intruder,  and  to 
encourage  the  patient  to  persevere  in  the  face  of  the  most  dis- 
heartening conditions.  Gold  was  out  of  the  question,  and  resort 
was  accordingly  had  to  amalgam,  the  cements,  _  and  gutta- 
percha. Even  then  the  cavities  were  often  not  well  prepared, 
through  fear  that  radical  methods  of  treatment  would  prove  too 
great  a  tax  on  the  patient  and  tip  the  balance  in  the  wrong  direc- 
tion, so  that  she  would  give  up  the  work  in  despair  and  let  the 
teeth  go.  At  times  during  those  trying  years  it  seemed  almost 
a  hopeless  case,  and  yet  the  sacrifice  of  losing  a  set  of  teeth  which 
in  appearance  were  really  beautiful  was  too  great  to  be  thought  of. 
The  patient  was  instructed  to  report  for  examination  every  three 
months.  Sometimes  she  would  appear  before  the  allotted  time 
with  the  stereotyped  remark,  "Doctor,  I  am  afraid  there  are 
other  cavities  coming."  And  they  usually  were  coming.  It 
grew  to  be  something  of  a  dread  to  have  this  patient's  name  an- 
nounced, and  yet  she  was  never  met  with  anything  but  the  most 
encouraging  demeanor,  and  the  idea  was  constantly  schooled 
into  her  that  those  teeth  must  be  saved  at  any  cost. 

This  kind  of  warfare  was  kept  up  till  she  was  sixteen  or  seven- 
teen, when  a  period  of  a  year  elapsed  without  her  reporting  at  the 
office,  and  the  natural  inference  was  that  she  had  finally  yielded 
to  what  seemed  the  inevitable  and  was  allowing  the  teeth  to  go  by 
default.  But  one  day  she  came  again  with  a  request  to  have  her 
teeth  examined,  saying  that  she  had  experienced  no  trouble  with 
them  in  the  interval,  but  thought  they  must  by  this  time  need 
attention.  The  first  glance  at  the  teeth  revealed  a  condition 
entirely  different  from  anything  that  had  ever  been  noted  in  that 
mouth  before,  and  the  dentist  realized  instantly  that  the  battle 


30  PRINCIPLES   AND    PRACTICE    OF    FILLING    TEETH 

had  at  last  been  won.  The  surfaces  of  the  teeth  were  clean  and 
bright,  and  the  gums  hard  and  normal.  When  questioned  as  to 
whether  she  had  given  the  teeth  .particular  attention  since  her 
last  visit  to  the  office,  the  patient  said  that  she  was  not  conscious 
of  having  done  more  than  the  ordinary. 

Since  then,  now  more  than  seven  years,  there  has  been  almost 
no  necessity  for  dental  service  in  that  moutH,  except  to  replace 
with  gold  the  worn-out  cement  and  gutta-percha  fillings  one  by  one 
as  they  failed.  To-day  the  young  lady  has  her  full  complement  of 
natural  teeth,  without  even  the  necessity  of  having  had  any  of 
them  crowned.  The  posterior  teeth  are  most  inartistically 
patched  and  plastered  with  amalgam,  but  from  an  anterior  view 
this  young  lady  would  be  credited  by  the  average  observer  with 
having  an  exceptionally  good  and  an  exceptionally  beautiful  set 
of  teeth. 

Such  a  result  as  this — and  the  case  here  recorded  is  by  no  means 
an  isolated  one — should  prove  of  the  greatest  possible  encourage- 
ment to  both  operator  and  patient,  and  should  stimulate  the 
practitioner  to  take  vigorously  in  hand  even  the  most  unpromising 
case  and  fight  back  the  disease,  no  matter  how  active  its  ravages 
appear  to  be.  Immunity  does  not  always  develop  so  suddenly 
or  so  completely  as  in  this  instance;  in  fact,  there  are  some 
patients  who  never  seem  to  become  immune,  but  in  the  vast 
majority  of  individuals  we  may  confidently  look  for  a  very 
appreciable  change  in  the  liability  to  decay  as  age  advances  from 
childhood  to  middle  life,  provided  we  take  stringent  measures 
to  control  the  difficulty.  It  would  seem  from  clinical  observation 
that  the  period  of  immunity  is  hastened  by  an  active  campaign 
against  the  development  of  caries,  whereby  the  occurrence  of 
large  cavities  is  avoided  and  the  teeth  are  kept  comfortable  for 
the  maintenance  of  a  full  functional  activity.  Neglected  cavities 
in  teeth  invite  decay  in  adjacent  teeth,  and  wherever  the  function 
of  mastication  is  interfered  with  through  sensitiveness  the  teeth 
in  that  locality  are  deprived  of  the  adequate  friction  to  keep  them 
free  from  adhesive  materials  of  a  character  calculated  to  bring 
about  decay.  The  highest  degree  of  health  in  the  mouth,  as 
elsewhere,  is  to  be  obtained  only  by  the  requisite  exercise  of  all 
the  functions,  and  this  cannot  ensue  where  the  teeth  are  sensitive 
from  decay  or  where  they  are  not  adequately  used  in  mastication. 
A  close  study  should  be  made  to  determine  whether  or  not  the 
patient  masticates  fully,  and  if  it  is  found  that  this  function  is  not 


DENTAL    CARIES  31 

properly  performed  the  patient  should  be  vigorously  schooled 
into  an  observance  of  its  necessity. 

It  is  of  the  very  greatest  importance,  if  immunity  is  to  be  estab- 
lished early  in  life,  that  the  most  strenuous  efforts  be  made  to 
check  the  disease  in  its  incipiency,  and  to  keep  a  watchful  eye 
over  the  general  condition  of  the  mouth  to  see  that  the  functions 
are  normally  active.  Nor  must  it  be  assumed  that  even  where  an 
apparent  immunity  has  been  once  established  the  case  will  invari- 
ably remain  permanently  immune.  Relapses  seem  as  likely  to 
occur  here  as  in  other  diseases,  though  they  are  usually  manifested 
in  a  different  manner,  and  they  do  not  necessarily  follow  the  initial 
attack  for  some  years.  In  the  case  just  recorded  the  probability 
is  that,  even  after  this  long  period  of  practical  immunity,  if 
the  young  lady  gets  married  and  is  called  upon  to  pass  through  all 
the  concomitant  vicissitudes  of  motherhood,  those  treacherous 
Httle  micro-organic  dogs  of  war  will  be  turned  loose  upon  her 
teeth  once  more,  and  there  will  be  another  contest  for  supremacy. 
Decay  will  commence  again  in  a  manner  to  discourage  any  practi- 
tioner who  has  not  a  well-defined  idea  as  to  the  usual  manifesta- 
tions of  periodical  susceptibility  and  immunity,  but  to  one  who 
is  accustomed  to  watching  these  cases  there  can  be  only  one  mind 
as  to  the  final  outcome,  provided  the  proper  course  is  pursued.  If 
the  case  is  met  in  a  vigorous  manner,  and  the  teeth  kept  comfort- 
able by  checking  the  decay  in  its  earliest  stages,  the  attack  will 
soon  pass  by  and  the  teeth  be  saved.  In  some  of  these  relapses, 
when  the  circumstances  are  such  that  the  patient  is  unable  to 
apply  to  the  dentist  with  sufficient  frequency,  a  pulp  is  occasion- 
ally lost  and  a  tooth  sometimes  breaks  down  to  the  degree  of 
requiring  a  crown,  but  this  is  usually  the  extent  of  the  disaster, 
and  the  mouth  is  still  maintained  in  full  functional  usefulness. 

As  has  been  intimated,  it  is  the  rarest  thing  to  find  a  case  where 
the  carious  process  is  uniformly  and  progressively  active  through 
life  if  anything  like  a  reasonable  attempt  is  made  to  check  it. 
There  are,  of  course,  many  cases  where  the  teeth  are  lost  one  after 
another  till  all  are  gone,  even  at  an  early  age  of  the  patient,  but 
these  are  usually  cases  where  no  adequate  attempt  has  been  made 
to  check  the  disease,  and  where  the  carious  process  has  had  the 
most  favorable  opportunity  to  advance. 

In  the  light  of  what  we  now  know,  it  may  be  laid  down  as  a 
conservative  statement  to  say  that  with  proper  attention  the 
teeth  of  most  individuals  may  be  saved  through  life,  so  far  as 


32  PRINCIPLES    AND    PRACTICE    OF    FILLnVG    TEETH 

decay  is  concerned,  and  it  is  confidently  believed  that  an  intel- 
ligent conception  on  the  part  of  the  profession  of  the  phenomena 
presented  ?;y  immunity  and  susceptibility  will  add  materially  to 
the  possibility  of  such  a  consummation.  If  the  operator's 
attention  is  constantly  directed  to  the  conditions  surrounding  the 
teeth,  rather  than  falling  back  on  the  old  fallacy  that  the  tendency 
to  decay  is  influenced  by  changes  in  the  structure  of  the  teeth, 
and  thus  entirely  out  of  his  reach,  it  will  place  him  in  a  more 
enlightened  relation  to  the  matter,  and  he  will  be  better  equipped 
to  meet  the  emergency  and  overcome  it.  That  there  is  a  dif- 
ference in  the  density  of  teeth  need  not  be  argued,  and  that  there 
is  a  wide  variation  in  the  behavior  of  teeth  under  the  action  of 
cutting  instruments  no  man  of  long  clinical  experience  will 
attempt  to  deny.  Some  teeth  may  be  cut  and  chiseled  away 
very  readily,  while  others  appear  to  cut  like  flint,  and  will  dull 
the  sharpest  and  hardest  instrument;  but  a  close  observation 
of  these  cases  would  seem  to  indicate  that  the  difference  in  resist- 
ing power  to  instruments  in  confined  largely  to  the  enamel,  and 
that  this  difference  is  due  more  to  the  variation  in  the  arrange- 
ment of  the  enamel-rods  than  to  variations  in  density.  In  some 
teeth  the  rods  stand  straight,  regular,  and  parallel;  in  others 
they  are  wavy  and  exceedingly  irregular  in  their  course.  It  is 
the  difference  between  straight-grained  maple  and  bird's-eye 
maple.  The  axe  will  readily  split  straight-grained  maple,  while 
bird's-eye  maple  is  stoutly  resistant.  It  is  practically  the  same 
with  the  different  kinds  of  enamel.  But  that  there  is  really 
little  variation  in  the  liability  to  decay  of  the  different  classes  of 
tooth-tissue  Dr.  Black's  investigations  proved  most  conclusively. 
The  hardest  tooth  that  was  ever  developed,  if  placed  in  a  mouth 
where  the  micro-organisms  are  perrriitted  to  form  their  gelatinous 
masses  and  produce  their  characteristic  acid,  will  promptly  be 
attacked  by  caries,  while  a  tooth  seemingly  friable  in  structure 
will  remain  free  from  caries  in  a  mouth  where  the  conditions  are 
unfavorable  to  such  action.  It  thus  seems  to  be  wholly  a  ques- 
tion of  environment,  though  it  is  not  here  intended  to  intimate 
that  the  denser  tooth  will  break  down  as  rapidly  under  the  carious 
process  when  it  has  once  started  as  will  the  one  of  less  resisting 
structure. 

That  well-formed  enamel  is  capable  of  being  attacked  is  amply 
demonstrated  by  the  location  of  many  of  the  cavities  we  find  in 
the  mouth.     The  proximal  surfaces  of  the  teeth  are  probably 


DJONTAL    f'AKIKH  'V-i 

attacked  as  ofU'ii  as  any  oilier,  and  at  tliis  prjint  wo  do  not 
ordinarily  look  for  defects  in  the;  tootfi-stiuctun;,  'Jliore  are  no 
pits  or  fissiir(!S,  and  the  (inamcil  is  laid  on  as  p(!rfectly  as  at  other 
surfaces  where  decay  seldom  occurs.  The  reason  wc  find  cavities 
in  th(!  proximal  surfaces  is  because;  of  the  (!nvironnient,  tlu;  posi- 
tion \)(''\r\g  sh(!lt(!red  and  free  from  the  friction  which  interfrires 
with  the  micro-organisms  on  exposed  surfaces.  Then,  again, 
we  learn  many  an  instructive  l(!Sson  in  the  examination  of 
d(!velopin(!ntal  defects  in  tooth-tissue.  We  ordinarily  look  for 
cavities  at  points  where  the  enamel  has  failed  in  continuity  of 
structure,  leaving  pits  or  fissures,  and  in  a  mouth  subject  to 
cari(!s  we  usually  find  initial  decay  at  th(!S(!  points.  But,  on  the 
other  hand,  we  frequently  see  cases  where,  on  account  of  im- 
munity, the  teeth  go  for  a  lifetime  containing  deep  fissurcjs 
entirely  through  the  cnarrKil  without  decay  occurring  in  any  of 
th(!m.  These  are  phenomcjna  which  should  command  the  closest 
att(!ntion  of  the  profession,  to  the  end  that  we  beconx;  familiar 
with  all  of  the  manifestations  of  dc^ntal  dcicay  and  have  an  in- 
telligent conception  of  its  true  nature. 

If  it  be  finally  proved  beyond  doul^t,  as  would  at  present  seem 
to  be  the  case,  that  the  question  of  condition  is  the  chief  factor  in 
this  disease,  then  it  devolves  upon  us  to  know  what  this  condition 
is,  and  to  treat  cases  scientifically  to  control  condition.  As  has 
already  been  intimated,  we  at  present  know  v(!ry  little  about  this 
subject  of  condition.  We  cannot  tell  what  particular  elements 
there  are  in  the  fluids  of  a  certain  mouth  tending  to  favor  the 
formation  of  these  micro-organic  films,  which  seem  to  be  the  main 
instrumentality  of  the  destructive  process,  nor  do  we  know  what 
constitutes  a  condition  unfavorable  to  them.  We  are  not  even 
clear  in  our  clinical  observations  as  to  surface  indications  which 
may  lead  us  to  judge  whether  a  mouth  is  susceptible  or  irnmunf;, 
except  as  we  see  caviti(!S  or  do  not  see  them.  And  yet,  even  with 
our  present  knowledge,  it  should  not  be  necessary,  if  we  are  truly 
obs(!rvant,  for  us  to  see;  actual  caries  in  ordrir  to  know  that  a 
mouth  is  susceptible.  There  are  unmistakable  evidences  present 
in  some  mouths  which  indicate  the  activity  of  the  carious  process 
to  one  who  has  closfsly  studicid  the;  rnatt(;r,  and  yfit  to  attempt  to 
describe  these  indications  so  that  they  will  1)0  intelligible  to 
others  seems  not  to  he.  easy  of  accomplishment.  They  relate 
rather  to  an  intuitive  percf!ptiori  of  general   conditions  on  the 

3 


34  PRINCIPLES   AND    PRACTICE    OF    FILLING    TEETH 

part  of  the  observer  than  to  any  definite  landmarks  in  the  mouth 
that  may  be  described. 

It  is  with  this  Hmitation  clearly  in  mind  that  a  few  hints  are 
herein  offered  for  observation,  with  the  suggestion  that  each 
practitioner  take  up  the  study  of  this  matter  in  his  own  experience 
till  he  secures  an  intelligent  basis  for  judgment. 

A  mouth  that  is  acutely  susceptible  will  ordinarily  present  an 
unkempt  appearance ;  not  necessarily  resulting  in  the  presence  of 
salivary  calculus,  but  apparently  indicating  that  the  teeth  are  not 
well  cared  for.  Accumulations  of  a  soft  nature  may  be  scraped 
from  the  surfaces,  as  if  the  patient  had  just  arisen  from  a  meal  of 
pasty  materials  and  had  not  even  rinsed  the  mouth.  The  fluids 
around  the  teeth  seem  to  contain  much  thick  mucus,  which  ren- 
ders the  semi-solid  substances  adhesive  to  the  surfaces  of  the 
enamel,  though  the  saliva  on  entering  the  mouth  at  the  orifices  of 
the  ducts  may  appear  of  normal  fluidity.  If  such  a  patient  is 
handed  a  glass  of  water  and  asked  to  rinse  the  mouth  thoroughly, 
it  will  be  found  that  after  the  attempt  is  made  the  teeth  are  left 
with  these  glutinous  accretions  still  clinging  to  them.  Nothing 
but  a  very  vigorous  rubbing  will  leave  the  teeth  reasonably 
smooth,  and  even  after  the  most  thorough  cleansing  it  is  only  a 
matter  of  a  few  hours  when  they  are  found  coated  again.  The 
first  impression  on  looking  into  such  a  mouth  is  that  the  patient 
ignores  dental  hygiene  altogether,  and  yet  some  of  these  cases 
are  at  least  as  well  cared  for  as  the  average.  It  simply  seems  an 
almost  impossible  task  to  keep  the  teeth  free  from  accumulations. 
If  a  thin,  flexible  scaler  be  passed  along  the  sheltered  surfaces  of 
the  teeth  it  will  almost  invariably  peel  up  a  film  of  gelatinous 
material,  and  even  the  occlusal  surfaces  of  such  teeth  are  never 
found  as  highly  polished  as  ordinarily.  The  teeth  seem  to  invite 
the  adhesion  of  materials  as  if  the  enamel  were  roughened,  and 
in  connection  with  this  the  gums  are  usually  found  more  or  less 
hypertrophied,  so  that  the  festoons  creep  up  over  the  teeth  more 
prominently  than  normal  and  bleed  on  the  slightest  touch.  This 
is  frequently  noted  in  such  cases,  even  where  there  are  no  cal- 
careous deposits  to  account  for  it.  A  mouth  in  this  condition 
should  be  watched  very  closely  with  the  expectancy  of  caries 
if  the  condition  persists  for  any  time. 

The  change  from  this  to  a  state  of  immunity  is  usually  marked 
by  a  general  clearing  up  of  the  fluids  of  the  mouth,  with  decreased 
viscidity  and  tenacity.     The  mouth  can  be  rinsed  tolerably  clean 


DENTAL   CARIES  35 

without  the  use  of  the  brush,  and  there  is  an  appearance  of 
cleanKness,  as  if  better  care  were  taken  of  the  teeth  even  in  cases 
where  no  change  has  been  made  in  the  patient's  habits  in  this 
regard.  There  is  httle  tendency  for  the  accumulation  of  foreign 
material  about  the  teeth,  and  the  impression  on  the  observer 
is  that  there  seems  to  be  some  kind  of  solvent  present  in  the 
mouth  which  keeps  the  fluids  clear  and  prevents  the  formation 
of  the  glutinous  masses  seen  during  the  susceptible  period. 
Coincident  with  this  the  gums  shrink  to  their  normal  form  and 
become  firm  and  pink,  and  do  not  readily  bleed  on  pressure. 

When  the  operator  observes  these  changes  going  on  in  a  mouth 
that  has  been  causing  him  unlimited  anxiety,  he  may  feel  much 
the  same  sense  of  elation  which  comes  over  a  physician  when  he 
finds  a  patient  who  has  been  suffering  from  a  high  and  stubborn 
fever  suddenly  bursting  out  into  a  generous  perspiration.  The 
tension  is  relieved,  and  for  the  time  at  least  the  dogs  of  war  are 
chained,  so  that  both  operator  and  patient  may  have  a  chance  to 
breathe. 

It  may  be  stated  in  passing  that  clinical  observation  would 
seem  to  prove  that  the  condition  of  immunity  may  be  brought 
about  earlier  by  a  rigorous  campaign  on  the  part  of  the  dentist 
and  the  patient  in  the  way  of  perfect  cleanliness  of  the  teeth,  and 
the  performance  of  all  necessary  operations  in  the  inception  of 
the  disease.  Neglected  teeth  seem  to  invite  and  continue  condi- 
tions of  susceptibility.  The  dentist  should  see  the  case  at  regular 
intervals  sufficiently  frequent  to  keep  a  close  supervision  of  the 
general  conditions  of  the  mouth.  If  the  teeth  become  stained  or 
covered  with  a  viscid  material  despite  the  efforts  of  the  patient, 
they  should  be  subjected  to  a  thorough  polishing  till  they  are 
made  white  and  glistening,  and  if  the  smallest  .cavity  presents  it 
should  be  J&Ued  at  once  before  it  contaminates  a  contiguous  sur- 
face. In  other  words,  the  environment  of  the  teeth  should  be 
carefully  looked  after,  and  the  decay  kept  down  to  the  smallest 
possible  limit.  It  is  in  this  connection  that  the  practice  of 
oral  prophylaxis,  as  already  outlined,  would  seem  to  offer  the 
most  satisfactory  service. 

The  practical  lesson  of  this  whole  study  of  susceptibility  and 
immunity  resolves  itself  into  the  fact  that  an  operator  is  never 
justified  in  allowing  even  the  worst  case  of  dental  caries  to  go  by 
default.  He  should  institute  the  most  vigorous  proceedings 
against  the  enemy,  with  the  idea  ever  in  mind  that  sooner  or  later 


36  PRINCIPLES    AND    PRACTICE    OF   FILLING    TEETH 

the  kindly  offices  of  beneficent  nature  will  intercede  and  help 
him  win  the  battle.  It  is  his  duty  in  the  darkest  hours  of  these 
trying  cases  to  explain  to  the  patient  as  clearly  as  he  may  the 
theory  of  immunity,  and  offer  such  encouragement  as  an  under- 
standing of  this  phenomenon  will  suggest.  By  so  doing  he  will 
often  carry  the  patient  through  a  disheartening  experience,  which 
otherwise  would  prove  sufficient  to  cause  a  total  neglect  and  loss 
of  the  teeth. 


CHAPTER  III 
EXAMINATION  OF  THE  TEETH  FOR  CARIES 

When  a  patient  selects  a  dentist  and  places  the  teeth  in  his 
charge,  it  is  the  dentist's  duty  to  make  a  careful  examination  of  the 
teeth  at  intervals  sufficiently  frequent  to  enable  him  to  keep  per- 
fect control  of  them  and  prevent  the  possibility  of  caries  even 
approaching  the  pulp,  much  less  causing  the  loss  of  a  tooth. 
There  should  be  a  definite  understanding  with  each  new  patron 
with  regard  to  the  mutual  responsibility  existing  between  opera- 
tor and  patient,  the  former  assuming  the  obligation  of  saving  the 
teeth  and  keeping  them  in  a  condition  of  functional  utility, 
barring  accidents  or  unforeseen  complications,  provided  the  latter 
will  faithfully  report  for  examination  at  stated  times  to  be  sug- 
gested by  the  dentist.  A  clear  understanding  of  this  nature  will 
not  only  stimulate  the  practitioner  to  his  best  endeavor,  but  will 
place  the  patient  in  such  a  relation  to  the  matter  as  to  lead  to 
increased  respect  and  appreciation  of  dental  service.  It  will  also 
establish  a  professional  and  personal  sentiment  between  the  two 
which  will  tend  finally  to  a  series  of  friendships  in  the  conduct 
of  a  practice  calculated  to  prove  one  of  the  most  pleasant  features 
of  professional  life. 

As  to  the  frequency  with  which  patients  shall  be  instructed  to 
apply  for  examination,  the  dentist  must  judge  on  the  basis  of  a 
stud}'-  of  each  case  in  its  relation  to  the  evident  tendency  or  other- 
wise to  decay  in  that  mouth.  In  some  particular  cases  where 
the  carious  process  seems  acutely  active,  the  teeth  should  be  seen 
as  often  as  every  second  month,  while  in  others  they  may  safely 
go  six  months.  But  in  no  case  where  decay  has  once  shown  itself 
should  the  patient  fail  to  apply  at  least  twice  a  year  for  examina- 
tion, and  in  the  meantime  should  report  immediately  on  the  ap- 
pearance of  any  suspicious  sensitiveness  in  the  teeth.  With 
patients  who  are  inclined  to  neglect  or  forget  these  examinations 
the  dentist  should  have  an  understanding  whereby  he  shall  notify 
them  at  regular  intervals  to  appear  for  inspection.     Appreciative 

37 


38  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

patients  take  very  kindly  to  the  idea  of  these  regular  notices  when 
they  understand  the  motive. 

All  operative  procedures  upon  the  teeth  should  be  pursued  in  a 
systematic  and  orderly  sequence,  even  one  apparently  so  simple 
as  the  examination  for  caries.  When  it  is  considered  that  each 
tooth  has  five  surfaces,  any  one  of  which  may  be  decayed,  it  will 
be  seen  that  to  properly  examine  an  entire  set  of  teeth  involves 
more  than  a  casual  glance  into  the  mouth,  such  as  is  often  made  to 
pass  muster  for  an  examination.  An  operator  owes  it  to  his 
patient  not  to  overlook  the  slightest  defect,  particularly  in  a 
mouth  where  caries  is  prevalent,  and  to  this  end  every  surface 
should  be  brought  under  critical  inspection.  To  accomplish 
this  at  the  expenditure  of  the  least  time  the  operator  should  have 
some  definite  starting  point  in  the  mouth,  and  proceed  from  this 
in  regular  order  till  the  entire  set  of  teeth  has  been  covered.  A 
convenient  place  to  begin  is  the  left  lower  third  molar,  and  from  this 
to  the  next  tooth  in  line  till  the  right  lower  third  molar  is  reached, 
when  the  mirror  may  be  turned  to  the  right  upper  third  molar, 
and  all  the  upper  teeth  examined,  ending  with  the  left  upper 
third  molar.  In  this  way  no  tooth  need  be  missed,  and  the 
least  possible  time  is  consumed  in  the  examination. 

Appliances  for  Examining  the  Teeth 

These  should  consist  of  a  mouth-mirror,  an  exploring  instru- 
ment, and  some  unwaxed  floss  silk.  The  mouth-mirror  is  an 
appliance  which  has  the  widest  possible  range  of  usefulness  in 
operative  dentistry.  It  begins  with  the  examination  of  the  teeth, 
and  ends  only  with  a  final  inspection  of  the  completed  operation. 
The  dentist  should  early  acquire  the  closest  familiarity  with  this 
appliance,  so  that  it  becomes  second  nature  with  him  to  con- 
stantly hold  it  in  his  left  hand  while  operating.  By  its  use  he  is 
able  to  discover  defects  in  the  teeth  which  his  unaided  eye  would 
never  reveal,  and  when  he  has  attained  a  thorough  mastery  of  it 
he  can  perform  many  operations  through  the  agency  of  the  image 
presented  in  the  glass  without  the  necessity  of  stooping  over  to 
look  directly  into  the  mouth.  In  any  operation  on  the  molars  or 
bicuspids,  even  where  direct  vision  is  possible,  the  work  is  greatly 
facilitated  by  reflecting  the  light  fully  upon  the  operation  with  the 
mirror. 

For  examining  the  teeth  this  reflected  light  is  very  valuable,  in 


EXAMINATION   OF   THE   TEETH   FOR    CARIES  39 

the  evidence  it  often  gives  of  caries  in  the  proximal  surfaces 
where  the  probe  fails  to  find  any  defect.  Sometimes  decay  occurs 
so  near  the  contact  point  that  the  exploring  instrument  cannot 
enter  it,  but  by  throwing  the  light  upon  the  teeth  the  enamel  will 
usually  show  a  different  color  from  normal  tooth-tissue.  This 
relates  to  a  dead  white  appearance  which  is  distinctive  in  charac- 
ter, and  readily  recognized  by  an  experienced  operator.  When 
this  appearance  is  noted,  and  there  seems  no  possibility  of  gaining 
entrance  to  the  cavity  with  the  finest  probe,  the  question  of 
whether  there  is  decay  or  not  may  often  puzzle  the  beginner.  It 
is  here  that  the  floss  silk  is  especially  useful.  If  drawn  between 
the  proximal  surfaces  of  the  teeth  where  caries  is  present  it  will 
usually  drag  and  fray  against  the  rough  margins  of  the  cavity, 
instead  of  passing  the  contact  points  with  a  snap,  as  is  the  case 
where  the  teeth  are  normal.  In  some  instances  the  floss  will 
be  severed  completely,  and  when  such  is  the  case  there  can  be 
no  longer  any  doubt  about  the  presence  of  a  cavity. 

The  exploring  instrument  is  especially  useful  for  investigating 
the  fissures  and  pits  of  the  occlusal  surfaces,  and  for  probing 
around  the  teeth  generally  wherever  the  light  from  the  glass 
cannot  penetrate.  It  should  be  very  fine  and  sharp  at  the  point, 
but  with  sufiicient  bulk  at  the  shank  to  make  it  reasonably  rigid. 

As  to  the  best  kind  of  mirror  for  ordinary  use  in  the  mouth,  it 
may  be  stated  incidentally  that  a  plane  mirror  is  preferable  to  a 
magnifying  mirror.  The  latter  so  distorts  the  image  as  to  be 
very  misleading,  while  a  plane  mirror  always  gives  the  true  image. 
In  critical  examinations,  where  the  image  requires  enlargement, 
a  good  magnifying  glass  is  very  useful,  but  never  a  magnifying 
mirror. 


CHAPTER  IV 
EXCLUSION  OF  MOISTURE  DURING  OPERATIONS 

One  of  the  chief  hindrances  to  the  execution  of  perfect  work  in 
the  mouth  is  the  saHva,  and  the  problem  accordingly  presents 
itself  of  keeping  the  teeth  free  from  moisture  during  operations. 
Various  methods  have  been  employed  for  this  purpose,  but  in  the 
majority  of  cases  the  only  effective  means  is  by  the  use  of  the 
rubber  dam  introduced  years  ago  by  Dr.  Barnum.  Previous  to 
the  introduction  of  the  rubber  dam  the  main  reliance  was  upon 
napkins,  and,  while  many  operators  became  very  proficient  in  their 
use,  there  was  never  the  security  that  is  readily  afforded  by  the 
dam.  Every  operator  should  become  an  expert  in  the  application 
of  the  dam,  to  the  end  that  he  may  avail  himself  of  its  advantages 
in  all  difficult  or  complicated  cases  of  treatment  or  filling.  The 
dam  is  not  used  as  much  as  it  should  be  by  many  operators,  on 
account  of  a  failure  to  thoroughly  master  its  ready  application, 
and  in  many  cases  it  is  made  to  work  unnecessary  hardships  on  the 
patient  through  faulty  methods  of  adjustment.  It  is  sufficiently 
unpleasant  to  most  people,  even  when  skillfully  used,  without 
adding  to  the  discomfort  by  bungling  or  awkwardness. 

The  greatest  consideration  should  invariably  be  exercised  on 
the  patient's  behalf;  not  only  in  the  adjustment  of  the  dam  itself, 
but  in  the  use  of  accessories,  such  as  clamps,  ligatures,  dam- 
holders,  weights,  etc.  Adequate  protection  to  the  patient's 
clothing  from  the  overflow  of  the  saliva,  particularly  when  operat- 
ing upon  the  lower  teeth,  should  be  provided  in  the  way  of  saliva 
ejectors,  napkins,  or  a  rubber  bib.  The  latter  is  especially 
serviceable,  and  should  always  be  at  hand  for  immediate  use  in  an 
emergency,  even  where  it  is  not  deemed  necessary  to  apply  it  at 
the  outset  of  the  operation.  The  saliva  ejector  in  many  instances 
seems  to  discommode  the  operator,  and  also  to  prove  with  some 
patients  more  of  an  annoyance  than  a  relief,  though  with  others 
it  is  a  very  acceptable  adjunct.  The  pecuhar  preferences  of 
patients  must  be  studied  in  this  as  in  other  matters. 

Where  the  ejector  cannot  be  used  the  chief  reliance  should  be 

40 


EXCLUSION    OF    MOISTURE    DURING    OPERATIONS 


41 


the  rubber  bib,  because  of  the  inadequate  protection  afforded  by 
napkins  from  the  tendency  of  the  saUva  to  soak  through  and 
reach  the  clothing.  It  need  not  be  intimated  that  the  bib  must 
be  kept  scrupulously  clean  at  all  times,  and  thoroughly  dried 
after  washing  before  being  used  on  another  patient. 

A  very  agreeable  accessory  to  the  use  of  the  dam  is  a  form  of 
napkin,  Fig.  21,  suggested  by  the  late  Dr.  J.  W.  Wassail,  to  be 
placed  between  the  dam  and  the  chin.     The  size  of  this  napkin  is 


Fig.  21. 

about  nine  inches  square,  and  the  greatest  depth  of  the  curvature 
about  three  inches  from  the  upper  margin.  Most  patients  are 
appreciative  of  this  attempt  to  keep  the  dam  away  from  the  face, 
and  it  is  especially  useful  in  cases  where  the  contact  of  the  dam 
has  a  tendency  to  induce  nausea.  The  curvature  in  the  pattern 
fits  approximately  the  outline  of  the  mouth,  and  the  two  ends 
may  be  tucked  up  under  the  dam-holder,  and  thus  be  held  in 
position  and  protect  the  cheek.  In  every  case  where  this  napkin 
is  not  used  a  smaller  napkin  should  be  folded  and  placed  between 
the  holder  and  the  face  on  either  side,  to  render  the  patient 
comfortable  and  prevent  the  imprint  of  the  holder  being  made  in 
the  cheek.  A  close  observance  of  these  minor  details,  as  they  affect 
the  comfort  of  the  patient,  will  do  much  toward  removing  the 


42  PEINCIPLES   AND    PRACTICE    OF    FILLING    TEETH 

prevalent  dread  of  dental  operations,  and  no  operator  can  afford 
to  neglect  them,  even  from  the  point  of  view  of  his  own  personal 
advantage. 

With  individuals  who  are  inclined  to  be  nauseated  by  the  rub- 
ber dam,  the  difficulty  may  often  be  overcome  by  diverting  atten- 
tion from  the  dam  in  the  following  manner:  Before  applying  the 
rubber  have  everything  in  readiness  to  proceed  at  once  with  the 
operation,  and  the  moment  the  dam  is  in  place  go  vigorously  at 
work  upon  the  tooth  with  something  of  a  hammer-and-tongs , 
method ;  not  necessarily  inflicting  undue  pain,  but  using  sufficient 
force  with  the  instrument  to  divert  the  patient's  attention  from  the 
dam  to  the  tooth.  Continue  this  rapidity  of  action  for  some 
minutes,  ignoring  all  attempts  at  protest,  and  directing  every 
energy  upon  the  operation  with  a  quick  succession  of  movements 
and  a  more  or  less  noisy  ratthng  of  instruments.  This,  if  pursued 
for  a  time,  will  usually  result  in  the  nausea  passing  away  and  the 
patient  quieting  down,  but  the  operation  must  be  carried  along  to 
completion  without  any  interruptions.  If  the  patient  be  left  for  a 
moment,  even  after  the  nausea  seems  to  have  passed,  the  sensation 
will  return  instantly  when  the  mind  is  allowed  to  dwell  upon  it. 
This  is  why  the  operator  must  seemingly  ignore  the  symptoms  of 
nausea  on  the  first  application  of  the  dam,  and  proceed  with  the 
work  irrespective  of  it.  If  he  quietly  waits  for  the  symptoms  to 
pass  away  they  will  never  pass,  but  grow  progressively  worse  till 
the  dam  must  be  removed.  This  is  only  one  of  many  cases  in 
dental  practice  where  a  bold,  rapid,  and  vigorous  policy  is  the  sole 
fine  of  procedure  capable  of  successfully  meeting  the  emergency. 

Kinds  of  Rubber  Dam 

The  weight  of  the  dam  is  largely  a  matter  of  individual  prefer- 
ence, some  operators  preferring  a  light  dam,  and  others  a  heavy 
one.  The  advantages  of  the  light,  or  thin,  dam  consist  in  its  more 
ready  passage  between  the  teeth,  and  its  consequent  greater  ease  of 
application ;  but  this  is  offset  by  the  fact  that  it  will  not  ordinarily 
remain  in  place  without  ligating,  and  it  is  too  readily  caught  up 
by  revolving  appliances,  such  as  disks  or  burs.  The  slightest  con- 
tact of  a  rotary  instrument  with  a  piece  of  thin  dam  will  cause  it 
to  be  wound  up  in  the  dam  so  as  to  tear  the  dam  or  puncture  it. 
On  the  other  hand,  very  heavy  dam,  while  ordinarily  more  diffi- 
cult to  apply,  will  to  a  greater  degree  admit  of  the  revolving 


EXCLUSION    OF    MOISTURE    DURING    OPERATIONS  43 

instrument  playing  over  its  surface  without  being  wound  up  or 
injured.  It  will  also  remain  more  securely  placed  on  the  teeth, 
and  seldom  requires  ligatures  to  hold  it.  But  with  some  teeth  the 
contact  of  the  proximating  surfaces  is  such  that  it  becomes  some- 
thing of  a  problem  to  force  thick  dam  between  them,  and  in  gen- 
eral practice  it  would  seem  best  to  employ  a  medium  weight  of 
dam. 

As  to  the  relative  advantages  of  the  twilled  dam  and  the  smooth 
dam,  the  operator  has  his  choice  between  a  dam  which  remains 
well  in  place  when  once  adjusted,  but  which  annoyingly  catches 
on  every  instrument  or  appliance  coming  in  contact  with  it,  and 
one  which  may  not  be  quite  so  tenacious  to  the  tooth,  but  which 
admits  of  reasonable  usage  without  annoyance.  The  twilled  dam 
seems  to  have  an  especial  propensity  for  being  caught  up  by  every 
movement  of  an  instrument  against  it,  and,  while  there  are  some 
operators  who  use  it  successfully  and  with  evident  satisfaction,  it 
will  prove  too  troublesome  for  general  recommendation. 

Size  of  Dam 

The  size  varies  according  to  the  particular  case  in  hand,  and  the 
location  in  the  mouth.  For  the  molars  it  should  be  about  seven 
inches  square,  and  ranging  from  this  down  to  six  inches  for  the 
incisors.  Some  operators  prefer  the  dam  cut  in  the  form  of  a 
triangle  by  dividing  a  square  piece  in  two  from  one  corner  to 
another,  the  long  base  of  the  triangle  being  placed  uppermost  and 
the  ends  grasped  by  the  dam-holder,  while  the  apex  hangs  down 
over  the  chin.  This  is  an  economical  way  of  cutting  the  dam, 
and  answers  a  good  purpose  in  the  anterior  part  of  the  mouth,  but 
for  posterior  teeth  the  square  form  is  preferable. 

Punching  the  Holes 

The  various  forms  of  rubber-dam  punches  may  be  used  for  mak- 
ing the  holes,  but  in  case  a  punch  is  not  available  a  very  simple 
and  very  effective  method  is  as  follows:  Take  a  round  instru- 
ment handle  about  four  millimeters  in  diameter,  slightly  oval- 
faced  on  its  end,  and  perfectly  smooth.  Over  this  stretch  the 
dam,  with  some  tension  at  the  point  where  the  hole  is  desired,  and 
with  a  sharp  knife  nick  the  dam  against  the  side  of  the  handle  a 
short  distance  from  the  end.  Fig.  22.     This  will  invariably  cut  out 


44 


PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 


a  perfectly  round  piece  of  rubber  and  leave  a  hole  as  true  and  clean 
in  outline  as  is  possible  with  the  sharpest  punch.  The  size  of  the 
hole  may  be  gauged  accurately  by  the  distance  from  the  end  of 
the  instrument  at  which  the  cut  is  made.  If  it  is  near  the  end,  the 
hole  will  be  small;  if  farther  away,  it  will  be  correspondingly  large. 
In  this  way  it  is  possible  to  vary  the  size  of  the  hole  from  the 
smallest  perceptible  puncture  to  a  hole  the  size  of  a  lead  pencil, 
and  still  have  a  clean-cut  outline. 


Fig.   22. 


The  sizes  required  for  the  different  teeth  will  vary  from  about 
three  millimeters  in  diameter  down  to  one  millimeter,  and  a  little 
practice  will  enable  the  operator  to  cut  the  holes  precisely  as 
desired.  The  width  of  rubber  between  the  holes  must  vary  ac- 
cording to  the  width  of  the  interproximal  spaces  and  the  condi- 
tion of  the  gum-septum  occupying  them.  If  the  teeth  are  long- 
crowned,  with  the  contact  point  near  the  occlusal  surface  and  the 
interproximal  space  large  and  imperfectly  filled  with  gum-tissue, 
the  width  of  dam  between  the  holes  must  be  great;  while  if  the 
teeth  are  short,  with  small  interproximal  spaces  and  the  gum 
coming  up  to  the  contact  point,  there  is  little  room  for  the  dam 
between  the  teeth,  and  it  must  be  correspondingly  narrow.  But 
it  should  never  be  made  so  narrow  that  it  fails  to  adequately  cover 
the  gum-septum  and  shut  out  moisture.  If  too  narrow,  it  will, 
when  stretched  between  the  teeth,  pass  down  to  one  side  of  the 
gum-septum  and  pinch  it  against  the  proximal  surface  of  the 
tooth,  leaving  part  of  the  gum  exposed  to  view,  instead  of  having 
it  wholly  covered.     The  width  of  dam  between  the  holes  should 


EXCLUSION    OF    MOISTURE    DURING    OPERATIONS  45 

vary  from  two  to  lour  millimeters  in  medium-weight  rubber — the 
lighter  the  rubber,  the  greater  the  width  necessary.  This  has  no 
relation  to  cases  of  unusual  spaces  between  teeth  where  the 
proximal  surfaces  are  not  in  contact,  and  where  the  width  of  dam 
must  be  governed  by  the  extent  of  separation. 

Rubber-Dam  Clamps 

The  use  of  clamps  for  the  purpose  of  holding  rubber  dam  in 
place  upon  the  teeth  has  been  much  misunderstood  and  greatly 
abused.  Clamps,  if  properly  selected  and  carefully  adjusted,  are 
capable  of  a  wide  range  of  usefulness,  but  if  employed  without  a 
knowledge  of  their  limitations  and  in  direct  violation  of  the  neces- 
sary care  and  skill,  as  they  frequently  seem  to  be,  they  are  calcu- 
lated to  work  irreparable  injury  to  the  teeth  and  surrounding  parts, 
and  involve  the  patient  in  much  needless  suffering. 

The  principal  faults  in  the  manipulation  of  clamps  consist  in  a 
failure  to  select  the  suitable  form  of  clamp  for  the  case  in  hand, 
and  a  lack  of  care  n  its  proper  adjustment.  A  clamp  that  does 
not  approximately  fit  the  tooth  cannot  be  expected  to  effectively 
remain  in  position  without  undue  impingement  at  certain  points, 
which  results  in  injury  and  discomfort.  An  operator  should  have 
a  sufficient  number  of  forms  to  meet  the  varying  cases  presented 
in  the  mouth,  and  to  this  end  should  make  a  careful  study  of  the 
different  teeth  with  especial  relation  to  the  shapes  of  the  crowns 
and  necks,  so  as  to  be  able  to  make  his  selection  of  clamps  with 
intelligence.  In  the  adjustment  of  a  clamp  harm  may  be  done 
in  two  ways :  the  clamp  may  be  too  small  for  the  tooth  and  pinch 
it  so  severely  at  the  neck  as  to  injure  the  tooth,  especially  in  a 
long  operation  where  the  slight  movement  of  the  clamp  resulting 
from  the  pressure  of  the  rubber  dam  against  the  bow  may  cause 
the  sharp  beaks  to  grind  against  the  enamel  so  as  to  indent  it; 
or  the  clamp  may  work  so  far  rootwise  on  the  tooth  as  to  cause  im- 
pingement on  the  gum  and  set  up  serious  inflammation.  Even  if 
this  injury  is  not  always  permanent,  it  is  sufficiently  distressing  to 
the  patient  to  account  for  future  distrust  and  apprehension  when- 
ever the  clamp  is  employed. 

The  rubber  dam  itself  is  sufficiently  objectionable  to  the  aver- 
age individual  without  adding  to  the  dread  by  painful  methods  of 
application,  and,  while  it  is  not  always  possible  to  maintain  the 
dam  in  place  without  some  slight  discomfort,  there  is  no  excuse 


46  PRINCIPLES   AND    PRACTICE    OF    FILLING    TEETH 

for  inflicting  the  serious  injury  in  its  use  that  is  too  often  done  by 
careless  operators.  The  clamp  may  be  used  in  the  large  majority 
of  cases  without  perceptible  pain  or  other  ill  effects,  if  properly 
selected  and  skillfully  applied.  The  two  classes  of  teeth  most 
difficult  to  manage  in  this  regard  are  those  of  the  extreme  bell- 
crowned  variety,  where  the  crowns  are  exceedingly  long  with 
broad  occlusal  surfaces,  and  the  short  conical  teeth  appearing  very 
little  above  the  gum.  In  the  former  case  the  contact  points  on 
the  proximal  surfaces  are  near  the  occlusal  surface,  and  the  inter- 
proximal spaces  are  large  and  long.  The  tooth  at  the  gingival 
line  is  much  narrower  in  circumference  than  at  the  occlusal  sur- 
face, and  the  buccal  and  lingual  surfaces  accordingly  present  an 
incline  toward  the  gum.  The  ordinary  clamp  applied  to  a  molar 
or  bicuspid  of  this  type  has  a  tendency  to  slide  along  this  incline 
and  gradually  impinge  seriously  upon  the  gum.  Every  movement 
of  the  rubber  dam  against  the  bow  of  the  clamp  tends  to  force  it 
still  farther  along  the  incline,  till  it  becomes  excruciating  to  the 
sensitive  gum-tissue.  To  obviate  this  difficulty  clamps  have  been 
devised  with  stays  on  the  bows  to  rest  on  the  occlusal  surface  of 
the  tooth,  with  the  idea  of  preventing  the  clamp  from  slipping 
too  far  rootwise,  but  in  many  cases  these  stays  do  not  prevent  the 
clamp  from  tipping  forward  and  gouging  the  anterior  point  of  the 
beak  in  the  gum,  and  in  other  cases  the  stays  are  in  the  way  of  the 
operation.  The  better  method  where  these  extreme  bell-crowned 
teeth  are  encountered  is  to  dispense  with  the  clamp  altogether  and 
secure  the  dam  by  some  other^means. 

The  other  form  of  tooth,  in  which  the  crown  is  short  and  the 
tooth  much  larger  in  circumference  at  the  free  margin  of  the  gum 
than  at  the  occlusal  surface,  presents  difficulties  of  a  vastly  dif- 
ferent character.  In  this  case  the  incline  is  from  the  gum  toward 
the  occlusal  surface,  and  the  chief  problem  presented  is  to  main- 
tain a  clamp  in  position  at  all.  The  inevitable  tendency  is  to  dis- 
lodge the  clamp  by  the  slightest  movement,  and  unless  the  clamp 
is  made  secure  in  the  beginning  of  the  operation  an  intricate  piece 
of  work  may  be  jeopardized,  and  even  ruined,  by  dislodgment  of 
the  clamp  when  the  operation  is  only  partially  completed.  In  this 
instance  there  is  little  danger  of  injuring  the  tooth  or  the  gum 
with  the  clamp.  It  may  cause  temporary  discomfort,  but  seldom 
permanent  injury.  The  gum  covers  the  enamel  to  such  an  extent 
that  the  enamel  is  thick  at  the  point  where  the  clamp  rests,  and  as 
for  the  gum,  it  will  usually  be  found  lapping  over  the  surface  of 


EXCLUSION    OF    MOISTURE    DURING    OPERATIONS  47 

the  tooth  to  a  considerable  distance  from  the  point  where  it  is 
attached  to  the  root.  This  flap  of  overlying  gum  may  safely  be 
forced  back  by  the  clamp  at  several  points  sufficiently  to  admit  a 
grip  of  the  beaks  without  permanent  injury,  provided  it  is  not 
pinched  by  the  beaks  or  severely  lacerated.  If  necessary,  a  local 
anesthetic  may  be  used  on  the  gum  before  applying  the  clamp, 
and  after  the  operation  an  anodyne  antiseptic  should  be  applied 
and  the  gum  gently  kneaded  against  the  buccal  and  lingual  sur- 
faces with  the  finger. 

For  extremely  difficult  cases  of  this  character,  such  as  are  some- 
times encountered  in  stunted  third  molars,  a  specially  devised 
clamp  is  indicated,  to  be  referred  to  subsequently. 

With  the  exception  of  these  two  classes  of  teeth,  and  the  peculiar 
difficulties  experienced  in  the  management  of  labial,  lingual,  or 
buccal  cavities,  the  ordinary  use  of  clamps,  if  properly  adjusted, 
ought  not  to  be  a  serious  dread  to  the  patient. 


KINDS  OF  CLAMPS 

Clamps  for  Molars  and  Bicuspids 

In  the  application  of  the  rubber  dam  to  molars  and  bicuspids, 
the  chief  problem  in  the  past  has  related  to  the  difficulty  of  carry- 
ing the  rubber  back  over  the  teeth  and  holding  it  there  while  the 
clamp  was  being  adjusted.  To  carry  the  dam  to  place  with  the 
fingers,  particularly  over  teeth  far  back  in  the  mouth,  was  exceed- 
ingly awkward,  and  in  some  cases  almost  impossible  without  dis- 
tressing the  patient.  To  overcome  this,  operators  were  in  the 
habit  of  passing  the  beaks  of  the  clamp  through  the  hole  in  the 
dam  and  carrying  the  clamp  and  rubber  to  place  at  once,  after- 
ward lifting  the  rubber  over  the  beaks  and  passing  it  between  them 
and  the  gum.  The  drawback  to  this,  with  beaks  of  the  ordinary 
form,  was  the  fact  that  the  rubber  stretched  across  the  opening 
between  the  beaks  and  obscured  the  tooth  so  that  it  was  difficult 
to  see  where  the  clamp  was  being  placed.  A  new  form  of  clamp 
was  devised  to  obviate  this,  known  as  the  Ivory  clamp,  in  which 
the  beaks  are  carried  out  buccally  and  lingually  and  then  turned 
down  into  a  flange,  over  which  the  rubber  may  be  hung,  leaving 
the  space  between  the  beaks  open  for  perfect  vision.  With  this 
form  of  clamp  the  application  of  the  rubber  dam  is  a  very  simple 
matter,  as  will  be  detailed  later. 


48 


PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 


Another  advantage  of  this  clamp  is  the  projecting  forward  of 
an  extension  from  each  beak  to  hold  the  rubber  out  of  the  way 
during  an  operation.  In  this  connection  it  may  be  stated  that 
one  of  the  chief  offices  of  the  clamp,  aside  from  its  service  in  main- 
taining the  rubber  on  the  tooth,  is  to  keep  it  away  from  the  region 
of  the  cavity,  so  that  it  shall  not  constantly  be  in  the  operator's 
light  and  be  caught  up  with  instruments  and  displaced.  The  bows 
of  the  clamp  accomplish  this  distally,  and  the  projections  on  the 
beaks  of  the  Ivory  clamp  do  it  buccally  and  lingually.  Figs.  23 
and  24  illustrate  the  Ivory  clamp  with  the  flanges  referred  to  and 


Fig.  25. 

the  manner  of  hanging  the  rubber  over  them.  Fig.  25  is  a  special 
form  of  beak  which  will  be  found  very  serviceable  for  those  diffi- 
cult cases  previously  referred  to — the  short  con  cal  teeth  whose 
buccal  and  lingual  surfaces  incline  sharply  toward  each  other  as 
they  pass  from  the  gum-margin  to  the  occlusal  surface,  so  as  to 
lead  to  the  displacement  of  an  ordinary  clamp.  As  will  be  seen, 
the  extremities  of  the  beaks  are  deflected  in  such  a  way  as  to  dip 
under  the  free  margin  of  the  gum  and  grasp  the  tooth  well  root- 
wise.  This  clamp  would  be  an  exceedingly  cruel  device  to  use 
in  ordinary  operating,  but  for  these  especially  trying  cases  it  will 
securely  maintain  the  rubber  in  place  when  no  other  form  of 
clamp  is  effective,  and  if  used  with  discriminating  care  it  need 
not  be  productive  of  any  serious  injury  or  discomfort  to  the 
patient. 


EXCLUSION    OF   MOISTURE    DURING    OPERATIONS  49 

The  operator  should  have  a  large  assortment  of  special  forms  of 
clamps  to  meet  all  the  special  cases,  but  for  ordinary  use  a  few  of 
the  standard  forms  of  molar  and  bicuspid  clamps  will  do  the  major 
part  of  the  work  in  the  routine  of  office  practice. 

Cervical  Clamps  for  Buccal,  Labial,  or  Lingual  Cavities 

With  the  large  range  of  service  demanded  of  a  cervical  clamp 
and  the  intricate  positions  it  is  sometimes  called  upon  to  reach,  it 
could  scarcely  be  expected  that  any  one  form  of  clamp  would 
advantageously  cover  all  cases.  Much  improvement  has  been 
made  in  recent  years  in  the  development  of  the  cervical  clamp, 
and  some  of  the  more  modern  forms  would  seem  to  be  as  nearly 
universal  as  ingenuity  can  make  them;  but  for  the  average  practi- 
tioner it  will  be  found  best  to  have  several  varieties  to  meet  all  of 
the  emergencies  that  may  present.  Some  operators  seem  to 
have  a  special  aptitude  for  one  particular  kind  of  clamp,  and  are 
apparently  able  to  accomplish  more  with  it  than  with  any  other; 
but  for  most  men  it  will  be  necessary  to  have  at  least  three  or 
four  forms  to  secure  the  best  results. 

The  forms  here  illustrated  are  not  intended  to  include  all  of  the 
serviceable  clamps  in  the  market,  but  with  these  in  his  case  the 
operator  will  be  reasonably  well  equipped  to  meet  most  cases 
applying  to  him  for  treatment.  Fig.  26  is  the  Keefe  clamp,  a 
feature  of  which  is  the  triple  bearing  on  the  tooth  afforded  by  the 
three  jaws  or  beaks.  This  tends  to  hold  the  clamp  securely  in 
place  and  prevent  rocking  when  screwed  down  snug  with  the 
set-screw.  To  provide  for  different  lengths  and  forms  of  teeth 
and  the  various  positions  of  cavities  two  of  the  beaks  are  made 
adjustable,  by  which  means  the  clamp  has  a  wide  longitudinal 
range  on  the  tooth,  so  as  to  be  carried  well  rootwise  in  cases  of 
extensive  caries.  In  using  this  clamp  it  should  first  be  carefully 
adjusted  to  the  tooth  before  the  rubber  is  in  place,  so  that  the 
operator  may  clearly  see  all  of  the  bearings  and  set  the  movable 
beaks  in  the  correct  position.  It  may  then  be  taken  from  the 
tooth,  the  rubber  adjusted,  and  the  clamp  returned  to  place,  after 
which  the  set-screw  may  be  turned  down  tight  to  hold  the  clamp 
firm. 

Fig.  27  represents  a  clamp,  which  is  intended  to  be  as  widely 
universal  as  possible.  It  is  adjustable  in  every  direction  and 
may  be  applied  to  a  wide  range  of  cases.  (The  author  has  not 
been  able  to  learn  the  name  of  this  clamp.) 


50 


PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 


Fig.  28  is  the  Libby  clamp,  made  in  a  right  and  left.  The 
distinctive  feature  of  this  clamp  is  the  hinged  beak  or  pivoted 
shoe  on  the  lingual  extremity,  which  enables  the  clamp  to  readily 
seek  a  bearing  and  remain  fixed  in  any  position  where  it  is  placed. 
This  clamp  should  be  carried  to  position  with  the  Brewer  clamp 
forceps.  Fig.  29;  and  when  once  properly  adjusted  it  maintains 
its  place  very  satisfactorily,  on  account  of  the  broad  bearing 
provided  by  the  hinged  apparatus  on  its  lingual  aspect.  The 
fact  that  the  extremity  of  this  usually  rests  against  the  gum 
renders  it  desirable  to  protect  the  gum  from  too  great  pressure  by 
slipping  a  short  section  of  half-inch  rubber  tubing  over  it  before 


Fig.  26. 


Fig.  27. 


Fig.  28. 


applying  the  clamp.  With  this  rubber  pad  properly  adjusted 
there  is  never  any  complaint  from  the  patient,  and  it  does  not 
seem  to  interfere  with  the  security  of  the  clamp, 

A  careful  study  of  the  proper  method  of  using  the  three  kinds 
of  clamps  here  illustrated  will  enable  the  operator  to  successfully 
meet  the  most  difficult  cases  which  apply  to  him  for  treatment, 
and  will  render  the  average  cases  very  easy  of  control.  In  some 
instances  the  clamp  will  need  to  be  steadied  by  the  fingers  of  the 
operator  to  make  certain  that  there  shall  be  no  movement,  but 
the  usual  length  of  time  necessary  to  complete  an  operation  of 
this  kind  ought  not  to  be  sufficiently  long  to  make  this  especially 
irksome. 

With  our  recent  methods  of  filling  most  of  these  cavities  occur- 
ring in  the  gingival  region  by  the  employment  of  inlays  or  silicate 
fillings  we  are  not  obliged  to  apply  the  dam  so  frequently  as 
formerly,  and  yet  every  operator  should  master  the  method 
perfectly  so  as  to  be  able  to  successfully  use  the  dam  when  needed. 


EXCLUSION    OF   MOISTURE    DURING    OPERATIONS  51 


Fig.  29. 


; 
52  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 


Ligatures 

In  operating  on  proximal  cavities  in  the  anterior  teeth  where 
clamps  are  not  indicated,  or  in  cases  of  bell-crowned  molars  and 
bicuspids  where  the  clamp  would  prove  too  cruel,  ligatures  may 
be  used  for  the  retention  of  the  dam  to  good  effect.  The  most 
serviceable  kind  of  ligature  is  waxed  floss  silk,  on  account  of  its 
great  strength  in  relation  to  its  bulk,  thereby  admitting  a  suffi- 
ciently strong  ligature  to  be  readily  forced  between  the  teeth. 

In  cases  where  the  dam  has  a  tendency  to  be  dragged  over  the 
ligature  and  become  displaced,  leaving  the  ligature  on  the  tooth, 
the  difficulty  may  be  overcome  by  the  use  of  small  glass  beads 
strung  on  the  ligature  and  distributed  at  various  points  around 
the  tooth.  On  a  molar,  for  instance,  where  the  tendency  would 
be  greatest  for  the  dam  to  slip,  a  bead  may  be  placed  respectively 
at  the  disto-buccal,  the  disto-lingual,  the  mesio-buccal,  and  the 
mesio-lingual  angles  of  the  tooth,  and  these  beads  will  present 
sufficient  bulk  to  resist  the  displacement  of  the  dam.  In  lieu  of 
beads  Dr.  E.  K.  Wedelstaedt  has  suggested  the  tying  of  a  small 
roll  of  cotton  in  the  ligature,  and  thus  creating  bulk.  The 
manner  of  adjusting  the  hgature  is  to  force  it  between  the  teeth 
on  the  distal  surface  of  the  tooth  to  be  ligated,  pass  it  around  the 
lingual  surface,  and  out  buccally  or  labially,  as  the  case  may  be, 
between  the  mesial  surface  of  this  tooth  and  the  distal  surface  of 
the  one  next  in  line.  The  two  ends  of  the  ligature  now  extend  o.ut 
so  the  operator  may  readily  grasp  them,  but  the  portion  embrac- 
ing the  tooth  is  usually  not  far  enough  rootwise.  Before  attempt- 
ing to  force  the  ligature  to  place,  the  first  loop  of  a  surgeon's 
knot  should  be  formed,  like  Fig.  30,  by  passing  one  end  of  the 
ligature  twice  around  the  other,  instead  of  once.  This  kind  of  a 
knot  will  hold  firm  when  drawn  tight  against  the  tooth  to  a 
greater  degree  than  where  the  ordinary  knot  is  used,  and  will 
thus  admit  of  the  second  loop  of  the  knot  being  tied  without  the 
hgature  loosening.  Before  drawing  the  first  loop  tight  the 
ligature  should  be  forced  as  far  rootwise  on  the  lingual  surface 
as  is  desired  with  an  instrument,  and  while  being  held  there  the 
strands'  of  the  ligature  may  be  carried  well  into  the  interproximal 
spaces  by  gentle  force  on  the  free  ends  exerted  in  an  oblique  di- 
rection buccally  (or  labially)  and  slightly  rootwise.  When  the 
ligature  on  the  mesial  and  distal  sides  of  the  tooth  has  glided  un- 
der the  free  margin  of  the  gum  and  carried  the  dam  with  it  the 


EXCLUSION    OF    MOISTURE    DURING    OPERATIONS  53 

first  loop  of  the  knot  may  be  drawn  tight,  which  will  securely 
fix  the  hgature  and  dam  in  place  till  the  second  loop  of  the  knot 
is  tied.  This 'second  loop  need  not  be  double-twisted,  as  the 
first.  When  the  ligature  is  thus  tied  the  free  ends  may  be  cut 
near  the  knot,  preferably  with  a  small  curved  pair  of  scissors 
like  manicure  scissors. 

A  very  effective  method  of  ligating  teeth  has  been  devised  by 
Dr.  Wedelstaedt  and  known  as  the  "Wedelstaedt  tie."  In  this 
method  the  double  twist,  as  shown  in  Fig.  30,  is  located  on  the 


Fig.  30. 

lingual  surface  of  the  tooth  instead  of  on  the  buccal  or  labial, 
and  the  two  ends  of  the  ligature  are  again  passed  between  the 
contact  points  so  as  to  extend  out  through  the  interproximal 
spaces  buccally  or  labially.  The  ligature  is  then  tightened 
around  the  tooth  by  grasping  the  ends  and  forcibly  exerting  trac- 
tion on  them  by  a  slight  movement  of  the  hand  back  and  forth. 
This  will  snug  the  ligature  up  into  the  interproximal  spaces  so  as 
to  grip  the  tooth  most  effectually,  and  when  tied  again  across 
the  buccal  or  labial  surface  it  furnishes  a  double-stranded  ligature 
completely  encircling  the  tooth  and  securely  holding  the  dam  in 
place. 

The  forcing  of  a  ligature  to  place  is  to  some  patients  painful, 
while  others  do  not  seem  to  mind  it  in  the  least,  the  difference 
being  due  to  the  natural  sensitiveness  of  certain  patients  more 
than  others,  and  also  to  the  fact  that  in  some  conditions  of  the 
gums  there  is  an  undue  tenderness  to  pressure  even  when  the 
individual  is  not  otherwise  nervous.  The  fact  that  the  ligature 
in  any  instance  may  give  pain  should  influence  the  operator  to 
dispense  with  it  whenever  possible,  and  in  actual  work  in  the 
mouth  this  may  be  done  to  a  very  large  degree.  If  the  dam 
is  of  the  proper  weight  and  is  skillfully  adjusted  it  is  the  exception, 
rather  than  the  rule,  for  a  hgature  to  be  required.     The  chief 


54  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

problem  of  retaining  the  dam  in  place  without  a  ligature  consists 
in  so  applying  the  dam  that  the  edges  of  the  holes  are  curled  up 
under  the  free  margin  of  the  gum  and  look  rootwise  instead  of 
crownwise.  If  this  can  be  accomplished,  the  rubber  will  ordina- 
rily remain  in  place  and  prevent  leakage  without  a  ligature.  To 
do  this  the  dam  should  be  stretched  rootwise  by  placing  the  ends 
of  the  fingers  over  the  dam  on  the  buccal  (or  labial)  and  lingual 
sides  of  the  hole,  and  forcing  it  against  the  gum  and  toward  the 
root.  If,  on  being  released,  the  dam  does  not  curl  up  to  position 
as  desired,  it  may  often  be  tucked  to  place  with  a  smooth  blunt- 
edged  instrument  like  an  amalgam  spatula  by  stretching  the  dam 
rootwise  and  sweeping  the  instrument  obliquely  along  under  the 
edge  of  the  dam  as  it  is  being  released.  Where  this  is  not  effect- 
ive the  dam  may  readily  be  curled  under  by  ligating  the  tooth, 
a  procedure  which  will  invariably  result  in  turning  the  edges  of 
the  dam  so  that  they  extend  rootwise.  If  it  is  a  case  where  there 
is  objection  to  the  ligature,  or  where  the  ligature  does  not  seem 
necessary  for  retaining  the  dam,  it  may  be  immediately  removed 
after  the  rubber  has  been  carried  to  place. 

Occasionally  it  is  necessary  to  ligate  only  one  or  two  teeth  in  a 
given  series  embraced  by  the  dam.  The  tooth  to  be  operated 
on  will  usually  require  ligating  to  secure  the  maintenance  of  the 
rubber  in  its  proper  place  and  prevent  leakage,  unless  a  clamp  is 
being  used.  If  the  cavity  is  a  proximal  one  it  is  -often  neces- 
sary to  ligate  the  tooth  next  in  line,  so  that  the  strip  of  dam  in  the 
interproximal  space  will  be  held  well  out  of  the  way  and  any 
possible  oozing  of  moisture  under  the  margin  of  the  dam  avoided. 
The  last  tooth  embraced  by  the  dam  and  farthest  from  operation 
may  also  require  ligating  to  prevent  the  rubber  from  being 
dragged  away  by  the  action  of  the  lips  or  the  tongue,  though  it 
will  frequently  be  found  that  ligating  can  be  dispensed  with  in 
such  a  case  by  merely  drawing  between  the  proximal  surface 
of  this  tooth  and  the  rubber  as  it  hangs  up  over  the  tooth  not 
embraced  by  it  a  single  strand  of  the  ligature  and  cutting  it  off, 
allowing  a  piece  of  the  strand  about  five  or  six  millimeters  in 
length  to  hang  as  a  wedge  between  the  dam  and  the  tooth  last 
embraced.  In  case  there  is  too  much  space  between  the  teeth 
to  render  the  strand  effective,  a  piece  of  rubber  may  be  sub- 
stituted for  it  by  using  an  ordinary  elastic  band  of  suitable 
size,  stretching  this  to  place,  and  cutting  it  the  proper  length. 

In  cases  where  there  is  appreciable  recession  of  the  gums, 


EXCLUSION    OF    MOISTURE    DURING    OPERATIONS  55 

leaving  the  interproximal  spaces  somewhat  open  and  admitting 
a  certain  amount  of  movement  to  the  dam  between 
the  teeth,  the  tendency  is  often  great  for  the  dam  to 
leak  unless  it  is  held  against  the  gum  and  kept  from 
movement.  To  ligate  all  of  the  teeth  is  usually  more 
or  less  distressing  to  the  patient,  besides  consuming 
time.  A  much  less  painful  and  a  more  rapid  method 
is  to  pack  a  bit  of  cotton  in  each  interproximal  space 
between  the  contact  points  of  the  teeth  and  the  rub- 
ber, forcing  the  cotton  well  up  toward  the  contact 
points  so  that  it  will  remain  wedged  to  place.  This 
will  usually  be  quite  effective  in  holding  the  rubber 
to  position  against  the  gum,  and,  if  done  with  care, 
need  not  give  the  patient  the  slightest  discomfort. 
The  operator  should  never  forget  to  remove  these 
little  cotton  plugs  before  attempting  to  take  off  the 
dam,  otherwise  he  is  likely  to  give  a  rather  uncom- 
fortable pull  to  the  dam  without  removing  it. 

In  every  instance  where  there  is  the  slightest  doubt 
about  the  dam  passing  readily  between  the  teeth,  a 
ligature  or  strip  of  rubber  should  first  be  carried 
between  all  of  the  teeth  to  be  embraced  by  the  dam, 
to  make  certain  that  the  spaces  are  clear  and  free 
from  rough  or  sharp  edges  calculated  to  cut  the  dam. 
Sometimes  bits  of  calculus  are  found  on  the  proximal 
surfaces,  and  these  should  invariably  be  removed 
before  the  dam  is  applied.  In  other  cases  incipient 
caries  may  have  begun  near  the  contact  point  on 
teeth  other  than  the  one  being  operated  on,  and  the 
sharp  margin  of  the  cavity  may  cut  the  ligature  or 
rubber.  To  obviate  this  a  thin  broad  instrument  like 
the  gum-depressor.  Fig.  31,  should  be  forced  between 
the  teeth  with  a  see-sawing  motion,  so  as  to  smooth 
the  rough  or  jagged  edges  of  enamel  in  advance  of  the 
application  of  the  dam.  This  instrument  may  tee 
readily  passed  between  the  contact  points  of  the 
teeth,  especially  if  the  edge  has  been  ground  quite 
thin,  and  after  its  free  passage  the  dam  may  be 
applied  with  safety.  ^°-  ^^^ 

When  the  teeth  are  thus  prepared  for  the  reception  of  the  dam, 
a  general  survey  of  the  situation  should  be  made  to  determine  the 


56  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

.required  location  of  the  holes.  For  the  lower  molar  teeth  the  last 
hole  back  should  be  about  three  inches  from  the  upper  edge  of 
the  dam,  and  about  two  and  one-half  or  three  inches  from  the 
edge  on  the  side  of  the  operation,  though  this  may  vary  some- 
what according  to  the  shape  of  the  jaws  and  lips  of  the  patient. 
For  lower  bicuspids  the  holes  may  be  somewhat  nearer  either 
edge,'  but  in  no  instance  should  they  be  near  enough  to  prevent 
the  dam  from  properly  covering  the  upper  lip  and  angles  of  the 
mouth.  For  the  upper  molars  or  bicuspids  the  last  hole  back 
need  not  be  more  than  two  inches  from  either  side.  Following 
this  point  forward,  the  holes  should  be  cut  so  as  to  correspond 
with  the  curve  of  the  arch,  and  in  every  instance  a  sufficient 
number  of  teeth  should  be  included  in  the  dam  to  properly 
expose  the  operation  to  view  and  keep  the  dam  well  out  of  the 
operator's  way.  It  is  too  frequently  the  case  that  operators 
hamper  themselves  in  their  work  by  including  only  one  or  two 
teeth  in  the  dam,  thereby  allowing  the  dam  to  curl  up  about  the 
cavity  and  hide  it  from  view,  besides  risking  the  danger  of 
continually  catching  the  dam  in  burs  or  other  revolving  instru- 
ments. There  may  be  occasional  instances  where,  on  account 
of  the  difficulty  of  applying  the  dam,  it  is  justifiable  to  limit 
as  far  as  possible  the  number  of  teeth  to  be  embraced  by  it, 
but  under  ordinary  conditions  in  operating  upon  the  molars 
or  bicuspids  the  dam  should  be  made  to  include  the  teeth  as  far 
foward  as  the  lateral  or  even  the  central  incisor.  Aside  from  the 
idea  of  having  the  dam  well  out  of  the  way,  there  is  an  anatomical 
reason  for  ending  at  one  of  the  incisors.  To  end  at  the  cuspid 
would  often  afford  the  operator  ample  opportunity  for  work,  but 
the  form  of  this  tooth  is  usually  such  as  to  render  it  unsuited  to  be 
the  last  tooth  embraced  by  the  dam.  It  is  often  so  cone-shaped 
that  the  dam  readily  draws  away  from  it,  while  the  mesial  sur- 
faces of  the  incisors  ordinarily  present  such  an  incline  as  to  prove 
an  excellent  medium  over  which  to  hang  the  last  hole  of  the  dam. 

Manner  of  Applying  the  Dam  in  Different  Locations  in  the  Mouth 

Before  applying  the  dam  to  any  of  the  teeth  the  enamel  should 
be  made  clean  by  a  thorough  rubbing  with  absolute  alcohol  on  a 
pellet  bf  cotton  to  remove  any  debris  which  may  be  clinging  to 
the  teeth  or  lodged  at  the  gum-margin.  Unless  this  precaution  is 
taken,  the  debris  containing  micro-organisms  may  be  forced  under 


EXCLUSION    OF    MOISTURE    DURING    OPERATIONS  o7 

the  free  margin  of  the  gum  by  the  dam  and  cause  undue  soreness 
through  infection,  by  being  held  in  contact  with  the  soft  tissues 
during  the  operation. 

To  apply  the  dam  to  the  lower  bicuspids  and  molars  the  opera- 
tor should  first  select  a  suitable  clamp  to  fit  the  last  tooth  back  to 
be  included  in  the  dam,  and,  after  hanging  the  dam  over  the 
flanges  of  the  clamp  and  adjusting  the  clamp  forceps,  he  should 
grasp  the  upper  edge  of  the  dam  with  the  thumb  and  fingers  of  the 
left  hand  in  such  a  way  as  to  stretch  the  dam  up  against  the  bow  of 
the  clamp  and  hold  the  edges  well  out  of  the  way  of  perfect  vision 
during  the  application.  Then,  standing  to  the  right  and  slightly 
in  front  of  the  patient,  with  the  chin  raised  sufficiently  to  look 
directly  into  the  mouth,  the  clamp  with  dam  attached  should  be 
carried  to  place  upon  the  tooth.  The  clamp  should  be  adjusted 
with  the  utmost  delicacy  and  gentleness,  so  as  to  inflict  the  least 
possible  discomfort.  In  some  instances  the  first  grip  of  the  clamp 
on  the  tooth  will  cause  a  slight  flinching  on  the  part  of  the  patient, 
but  if  it  is  a  clamp  of  the  proper  form  for  the  case  in  hand  and  is 
carefully  applied  all  appreciable  discomfort  passes  away  in  a 
moment.  Immediately  following  the  placement  of  the  clamp  the 
forceps  should  be  laid  aside  and  a  pair  of  pliers  or  a  thin-bladed 
spatula  should  be  employed  to  lift  the  rubber  free  from  the 
flanges  of  the  clamp,  so  as  to  let  it  snap  around  the  tooth.  The 
dam  thus  fixed,  the  edges  may  be  fastened  back  out  of  the  way, 
with  the  dam-holder  around  the  patient's  head,  when  both  hands 
will  be  free  for  the  further  adjustment  of  the  dam  over  the  remain- 
ing teeth.  With  the  number  of  holes  in  the  dam  already  fixed 
in  his  mind,  the  operator  should  count  back  toward  the  tooth 
embraced  by  the  clamp  to  be  assured  that  he  is  placing  each  hole 
over  the  proper  tooth,  otherwise  he  may  make  the  mistake  of 
leaving  a  hole  in  the  dam  between  the  tooth  embraced  by  the 
clamp  and  the  one  in  front  of  it.  Then,  starting  at  the  tooth  next 
to  the  one  already  exposed  by  the  clamp,  he  should  consecutively 
pass  the  rubber  over  each  tooth  till  all  are  included.  This  should 
be  done  by  forcing  the  edge  of  the  dam  bordering  the  hole  past  the 
contact  points,  and  thus  carrying  the  strip  of  rubber  between  the 
holes  into  the  interproximal  space.  If  at  any  point  the  rubber 
seems  to  stick  and  refuses  to  pass  between  the  teeth  short  of  suffi- 
cient stretching  to  risk  the  danger  of  tearing  the  dam,  the  rubber 
should  be  merely  hung  over  this  particular  tooth  while  the  opera- 
tor passes  to  the  others  and  slips  the  dam  over  them.     Then  the 


58 


PRINCIPLES    AND    PRACTICE    OP    FILLING    TEETH 


ligature  may  be  used  to  force  the  dam  past  the  difficult  spaces,  and 
a  careful  examination  made  to  see  that  there  are  no  points  at  which 
a  leak  may  occur.  In  doing  this  the  distal  surface  of  the  tooth 
embraced  by  the  clamp  must  not  be  overlooked.  If  the  dam 
hangs  over  this  tooth  so  as  to  invite  leakage,  the  ligature  should 
be  used  to  carry  the  dam  well  between  this  tooth  and  the  one 
back  of  it. 

After  the  proper  adjustment  of  the  dam  the  comfort  of  the 
patient  must  be  looked  to,  as  previously  indicated,  by  the  use  of 
napkins,  cheek  pads,  rubber  bibs,  etc.  If  the  lower  edges  of  the 
dam  exhibit  an  inclination  to  curl  up  in  the  operator's  way,  they 
may  be  fastened  down  by  weights. 


Fig.  32. 

In  applying  the  dam  to  the  upper  bicuspids  and  molars  the  plan 
of  procedure  is  much  the  same  as  for  the  lower  teeth,  except  that 
some  of  the  motions  must  be  reversed,  and  the  position  of  the 
patient  and  operator  slightly  changed.  The  grasp  of  the  clamp 
forceps  is  also  different.  When  adjusting  the  clamp  to  the  lower 
teeth  the  forceps  is  placed  with  the  claws  looking  downward,  and 


EXCLUSION    OF    MOISTURE   DURING    OPERATIONS 


59 


the  handles  are  grasped  in  the  palm  of  the  hand  with  the  back  of 
the  hand  upward  and  the  thumb  pressing  against  the  outside  of 
the  handle  nearest  the  operator  close  to  the  hinge,  while  the 
fingers  reach  over  and  clasp  the  handle  farthest  from  the  operator 
(Fig.  32). 

For  the  upper  teeth  the  claws  of  the  forceps  look  upward  and 
the  back  of  the  operator's  hand  downward.  The  handles  of  the 
forceps  pass  diagonally  across  the  palm  between  the  second  and 


Fig.  33. 


third  fingers  and  out  between  the  thumb  and  index  finger,  so  that 
the  handles  near  the  end  are  grasped  by  the  thumb  and  index 
finger,  and  farther  down  toward  the  hinge  by  the  second  and  third 
fingers  The  ends  of  the  index  and  second  fingers  clasp  around 
and  over  the  top  of  the  handle  farthest  from  the  operator,  while 
the  thumb  clasps  around  and  over  the  top  of  the  handle  nearest 
him,  and  the  ends  of  all  three  are  turned  so  as  to  look  somewhat  in 
the  direction  of  the  claws.     Thus  the  only  finger  not  touching  the 


60  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

forceps  is  the  little  finger,  and  the  principal  grasping  force  is 
exerted  by  the  index  finger  and  the  thumb,  while  the  lifting  force 
in  carrying  the  clamp  to  place  is  exerted  by  the  third  finger  as  the 
handle  lies  across  it  (Fig.  33). 

In  adjusting  the  dam  to  the  upper  teeth  the  patient's  head 
should  be  tipped  back  so  as  to  expose  these  teeth  as  perfectly  as 
possible,  and  for  the  right  side  of  the  mouth  the  operator  should 
stand  to  the  right  and  in  front  of  the  patient  with  the  patient's 
head  slightly  turned  to  the  right,  so  as  to  present  the  occlusal  sur- 
faces of  the  teeth  directly  toward  the  operator,  the  chin  being 
raised  to  a  convenient  height  for  this  purpose. 

On  the  left  side  of  the  mouth  the  teeth  can  often  be  better  ap- 
proached by  slightly  lowering  the  chair  and  stepping  a  trifle  to  the 
back  of  the  patient,  so  as  to  pass  the  left  hand  and  arm  over  and 
around  the  patient's  head  to  hold  the  upper  edge  of  the  rubber 
away  while  the  right  hand  is  manipulating  the  forceps.  The 
operator  should  study  carefully  the  various  peculiarities  of  form 
and  position  presented  by  the  different  mouths  and  teeth  of  indi- 
viduals, so  as  thereby  to  avail  himself  of  every  advantage  which 
his  ingenuity  may  suggest.  There  is  always  a  best  and  handiest 
way  of  doing  these  things,  but  no  one  way  is  always  the  best  nor 
the  handiest,  and  to  gain  the  most,  satisfactory  results  in  every 
case  the  operator  must  be  prepare^'  to  vary  his  methods,  so  far  at 
least  as  the  minor  details  of  execution  are  concerned. 

For  the  upper  incisors  and  cuspids  the  holes  should  be  punched 
in  the  dam  from  an  inch  and  a  half  to  two  inches  from  the  upper 
edge,  depending  on  the  case.  The  former  distance  will  be  ample 
in  most  instances,  but  for  a  gentleman  patient  with  a  large 
moustache  the  holes  should  be  at  least  two  inches  from  the  edge, 
to  afford  sufficient  area  of  dam  to  perfectly  cover  the  moustache 
and  hold  it  out  of  the  way.  In  no  case  should  the  dam  be  allowed 
to  pass  over  the  nostrils  and  obstruct  the  patient's  breathing.  For 
the  lower  anterior  teeth  the  holes  should  be  from  three  inches  to 
three  inches  and  a  half  from  the  upper  margin,  so  that  the  mouth 
may  be  thrown  well  open  and  still  admit  of  the  dam  extending 
over  the  upper  lip. 

To  adjust  the  rubber  to  the  upper  anterior  teeth  the  upper  edge 
of  the  dam  should  be  grasped  by  the  left  hand  in  such  a  manner 
that  the  back  of  the  hand  looks  away  from  the  patient's  face,  while 
the  palm  is  turned  toward  the  face  and  the  ends  of  the  fingers 
look  downward  with  the  elbow  raised  over  the  patient's  head. 


EXCLUSION    OF   MOISTURE    DURING    OPERATIONS 


61 


The  dam  should  pass  between  the  thumb  and  index  finger  and  out 
again  between  the  third  and  Httle  fingers,  so  that  the  index,  second, 
and  third  fingers  are  exposed  to  the  operator's  view  as  he  looks  at 
the  back  of  his  hand  while  the  ends  of  the  thumb  and  little  finger 
are  covered  by  the  dam.  The  grasp  of  the  dam  therefore  comes 
in  two  places,  between  the  thumb  and  index  finger  and  between 
the  third  and  little  fingers,  thus  keeping  the  dam  on  a  tension  and 
leaving  the  second  finger  free  to  stretch  the  holes.     The  end  of 


Fig.  34. 

the  second  finger  should  be  placed  at  the  upper  margin  of  the  hoel 
which  is  to  embrace  the  tooth  farthest  to  the  left,  and  opposite 
this,  on  the  lower  margin  of  the  same  hole,  should  be  placed  the 
end  of  the  index  finger  of  the  right  hand,  while  the  rubber  extends 
from  this  down  into  the  palm  of  the  right  hand  and  is  grasped  by 
gathering  the  edge  nearest  the  operator  between  the  thumb  and 
palm  on  the  one  side  and  the  second,  third,  and  little  fingers  on 
the  other,  the  thumb  extending  between  the  dam  and  the  patient's 
chin,  while  the  ends  of  the  fingers  are  curled  well  up  into  the  palm 
to  readily  bring  the  rubber  on  a  tension.     This  leaves  the  index 


62  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

finger  free  to  work  in  conjunction  with  the  second  finger  of  the 
left  hand  in  stretching  and  forcing  the  holes  over  the  teeth 
(Fig.  34) ._ 

Beginning  with  the  tooth  farthest  to  the  left,  the  dam  should 
be  carried  consecutively  over  each  tooth  toward  the  right  till  all 
are  included.  The  strips  of  dam  between  the  holes  should  be 
forced  well  into  the  interproximal  spaces  by  a  see-sawing  or 
stretching  motion  exerted  by  the  second  finger  of  the  left  hand 
and  the  index  finger  of  the  right,  so  that  if  possible  the  edges 
of  the  dam  around  the  holes  are  turned  under  the  free  margin 
of  the  gums  and  look  rootwise.  The  outer  edges  of  the  dam 
may  now  be  fastened  back  with  the  holder,  after  which  ligatures 
may  be  applied  wherever  necessary,  and  the  comfort  of  the 
patient  looked  after  as  previously  indicated. 


Fig.  35. 

For  the  anterior  teeth  of  the  lower  jaw  the  grasp  of  the  rubber 
in  the  left  hand  is  practically  the  same  as  for  the  upper  teeth,  but 
the  grasp  with  the  right  hand  is  entirely  different.  Instead  of 
gathering  the  edge  of  the  dam  nearest  the  operator  in  the  palm, 
the  grasp  is  made  from  the  lower  margin  of  the  dam  with  the 
thumb  uppermost.     The  grip  is  exerted  by  curling  all  four  fin- 


EXCLUSION    OF    MOISTURE    DURING    OPERATIONS  63 

g^rs  up  into  the  palm  and  gathering  the  lower  edge  of  the  rubVjer 
between  the  ends  of  the  fingers  and  the  palm.  This  leaves  the 
thumb  free  to  stretch  the  holes  over  the  teeth  in  conjunction  with 
the  second  finger  of  the  left  hand  (Fig.  35).  But  the  method  of 
forcing  the  dam  to  place  is  different  from  that  of  the  upper  teeth. 
When  stretching  the  holes  over  the  upper  teeth  the  end  of  the 
second  finger  of  the  left  hand  is  carried  along  the  labial  surface 
of  the  tooth,  while  with  the  lower  teeth  it  is  carried  into  the  mouth 
and  along  the  ingual  surface,  the  thumb  forcing  the  dam  over 
the  labial  surfaces. 

To  gain  an  intelligent  conception  of  the  methods  of  procedure 
here  outlined,  both  as  regards  the  handling  of  the  clamp  forceps 
and  the  various  grasps  of  the  rubber  dam,  the  beginner  would 
better  follow  out  the  descriptions  with  the  forceps  and  dam  in  his 
hands.  It  is  too  often  the  case  that  descriptions  which  read  well 
prove  impracticable  when  applied  to  the  mouth,  while  methods 
which  appear  cumbrous  in  print  are  very  effective  in  their  practi- 
cal application.  It  is  with  this  idea  in  mind  that,  in  conjunction 
with  the  writing  of  these  descriptions,  an  actual  adjustment  of 
the  dam  has  been  made  in  each  instance. 

Applying  the  Dam  for  Operations  on  Buccal,  Labial,  or  Lingual 

Cavities 

The  peculiar  difficulties  to  be  encountered  in  controlling  these 
cases  relate  to  the  rootwise  extension  of  the  decay,  and  the  conse- 
quent involvement  of  the  gum-tissue  in  the  cavity.  In  some  in- 
stances the  gum  fills  more  than  one-half  the  cavity,  and  the  prob- 
lem then  is  to  displace  the  gum  so  as  to  expose  the  gingival  margin 
of  the  cavity  and  admit  of  carrying  the  clamp  and  rubber  rootwise 
of  it.  This  may  be  done  in  one  of  several  ways.  Where  a  large 
mass  of  hypertrophied  gum-tissue  fills  the  cavity  it  should  be  cut 
away  with  a  lancet  or  curved  scissors,  and  then  the  cavity  packed 
with  gutta-percha  in  the  form  of  a  soft  temporary  stopping,  with 
considerable  excess  extending  over  the  gingival  margin  of  the 
cavity  so  as  to  force  the  gum  well  away  from  this  region.  This 
should  be  allowed  to  remain  two  or  three  days,  when  the  gum  will 
be  found  well  healed  and  the  cavity-margin  exposed.  In  many 
cases  the  temporary  stopping  will  accomplish  the  object  without 
previous  cutting  of  the  gum,  and  in  case  it  is  difficult  to  maintain 
in  place,  on  account  of  the  form  of  the  cavity,  it  may  be  secured 


64  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

by  passing  a  ligature  around  the  tooth  and  over  the  gutta-percha, 
thus  tying  it  to  position. 

In  some  cases  the  decay  extends  over  the  surface  of  the  tooth 
and  under  the  gum  for  considerable  distance  without  appreciable 
penetration  into  the  tooth,  so  that  gutta-percha  cannot  in  any  way 
be  employed  to  force  back  the  gum.  The  only  alternative  is 
to  press  away  the  gum  with  the  clamp  at  the  time  of  operating,  or, 
if  this  cannot  be  done,  to  make  a  vertical  incision  in  the  gum  over 
the  cavity,  reaching  from  the  gum-margin  rootwise  past  the  de- 
cay. The  flaps  of  gum  may  then  be  forced  out  of  the  way,  and 
after  the  filling  is  completed  they  will  readily  heal, 
provided  care  is  taken  not  to  produce  too  much 
laceration  (Fig.  36). 

The  operation  should  be  performed  with  anti- 
septic precaution,  and  after  the  clamp  is  removed 
the  flaps  of  gum  should  be  gently  kneaded  into 
position  with  the  fingers  and  held  with  the  severed 
edges  pinched  together  for  a  few  minutes.  The 
patient  should  be  warned  against  using  the  tooth-brush  upon 
the  gum  till  it  is  perfectly  healed,  but  in  the  meantime  to  bathe 
it  with  an  antiseptic  mouth-wash  several  times  a  day  and  gently 
massage  it  over  the  filling. 

With  the  gingival  margin  of  the  cavity  thus  exposed  one  of  the 
chief  difficulties  in  the  application  of  the  dam  is  removed,  but  a 
minor  one  instantly  presents  itself  in  the  fact  that  the  cavity 
extends  so  much  farther  rootwise  than  the  gum  on  the  opposite 
side  of  the  tooth  that  the  jaws  of  the  clamp  do  not  impinge  on  the 
tooth  at  points  directly  opposed  to  each  other.  This  results  in 
insecurity  of  the  clamp  unless  specially  provided  for.  With  the 
Keefe  clamp  this  difficulty  is  overcome  by  the  adjustable  jaws 
and  the  triple  bearing,  in  the  Libby  by  the  pivoted  shoe  for  the 
lingual  surface,  and  in  Fig.  27  by  adjusting  the  swivel  so  that 
the  points  of  bearing  may  be  arranged  directly  opposite  one 
another.  It  is  of  the  utmost  importance  to  test  the  various 
clamps  on  the  tooth  before  the  application  of  the  dam,  so  that  a 
suitable  selection  may  be  made  for  the  case  in  hand. 

In  making  holes  in  the  dam  for  these  cavities  they  should  be 
punched  farther  apart  than  for  other  cavities,  so  as  to  admit  of 
considerable  stretching  of  the  strips  between  the  holes  without 
drawing  them  too  thin  or  too  narrow. 


EXCLUSION    OF    MOISTURE    DURING    OPERATIONS  65 

Application  of  the  Dam  in  Difficult  Cases 
It  is  seldom  that  the  dam  cannot  be  readily  applied  to  any  of  the 
anterior  teeth  and  securely  retained  in  place,  but  with  the  molars, 
particularly  the  second  and  third  molai-s,  the  problem  sometimes 
becomes  more  or  less  complicated.  The  chief  difficulties  relate  to 
peculiar  forms  of  teeth,  unfavorable  positions  of  teeth,  bad  con- 
tacts on  the  proximal  surfaces,  and  a  general  tendency  to  resist- 
ance on  the  part  of  the  patient. 

The  forms  of  teeth  most  unsuited  for  the  retention  of  the  clamp 
are  those  of  a  cone-shape,  with  buccal  and  lingual  surfaces  so 
sloped  that  the  clamp  is  invariably  displaced  unless  made  of  a 
peculiar  pattern.  Teeth  of  this  character  are  much  larger  in  cir- 
cumference at  the  gum-margin  than  at  the  occlusal  surface,  and 
there  is  consequently  no  opportunity  for  the  grip  of  an  ordinary 
clamp.  But  if  a  close  study  be  made  of  these  teeth  it  will  usually 
be  found  that  a  short  distance  under  the  free  margin  of  the  gum 
there  is  a  slight  depression  as  the  enamel  approaches  its  thin  edge 
near  the  cementum.  The  gum  is  never  adherent  to  the  tooth  at 
this  point,  and  with  a  clamp  so  formed  that  the  jaws  are  turned 
down  into  a  reasonably  sharp  projection  at  either  extremity,  so 
as  readily  to  slip  under  the  free  margin  of  the  gum,  an  adequate 
grip  may  be  obtained,  provided  the  patient  will  submit  to  a  slight 
temporary  discomfort.  Such  a  clamp  has  already  been  referred 
to  in  Pig.  25,  and  if  this  clamp  is  used  with  discriminating  judg- 
ment it  will  be  found  very  effective  without  the  infliction  of  any 
serious  pain.  It  should  be  applied  with  the  Brewer  forceps, 
the  bows  of  the  clamp  necessarily  being  very  rigid  and  the  jaws 
not  readily  spread  with  the  ordinary  forceps. 

Unfavorable  positions  of  the  tooth  relate  particularly  to  upper 
third  molars  which  are  turned  outward  so  that  their  occlusal  sur- 
faces look  somewhat  toward  the  cheek.  In  these  cases  it  is  often 
found  that  on  opening  the  moilth  the  anterior  border  of  the  ramus 
of  the  lower  jaw  is  carried  forward,  so  as  to  impinge  against  the 
bow  of  the  clamp.  This  difficulty  may  be  overcome  by  using  a 
clamp  with  a  small  bow  and  applying  it  in  the  following  way: 
After  carrying  the  clamp  into  the  mouth,  and  before  any  attempt 
is  made  to  place  it  over  the  tooth,  the  angle  of  the  lips  on  the 
side  of  the  operation  should  be  stretched  well  out  and  back  with 
the  fingers  of  the  left  hand,  so  as  to  expose  the  buccal  surfaces  of 
the  upper  molars  to  view;  and  then  the  patient  should  be  instructed 
to  close  the  mouth  as  far  as  possible.     This  will  immediately  throw 


66  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

the  ramus  back  out  of  the  way  and  further  loosen  the  tension  of 
the  cheek  and  hps,  so  a  better  view  is  had  and  an  adequate  space 
left  to  slip  the  clamp  to  place.  It  will  be  found  that  in  operating 
on  these  teeth  there  is  little  necessity  for  keeping  the  jaws  very 
far  apart,  particularly  if  the  operator  is  expert  in  the  use  of  the 
mouth-mirror.  All  of  the  work  on  these  teeth  after  the  applica- 
tion of  the  dam  should  be  performed  through  the  reflection  of  the 
mirror,  with  the  operator  standing  erect.  By  this  method  these 
cases  are  readily  met  and  the  difficulty  overcome. 

In  some  instances  on  the  lower  jaw  the  ridge  of  bone  extend- 
ing forward  from  the  ramus  is  so  prominent 
opposite  the  buccal  surface  of  the  third 
molar  as  to  interfere  with  the  application  of 
an  ordinary  clamp,  and  in  such  a  case  the 
Southwick  clamp,  Fig.  37,  is  indicated.    This  ^ig.  37. 

clamp  is  made  in  four  sizes,  and  should  be  in 
every  operating  case.     It  is  often  applicable  to  the  upper  teeth 
as  well  as  the  lower. 

Bad  contacts  between  teeth,  interfering  most  seriously  with 
the  adjustment  of  the  dam,  are  found  in  cases  where  slight  decay 
has  commenced  near  the  contact  point,  leaving  sharp  edges 
of  enamel  calculated  to  cut  the  dam,  and  also  where  there  has 
been  extensive  wear  of  the  teeth  on  the  proximal  surfaces  from 
the  individual  movement  of  the  teeth  one  against  the  other, 
resulting  in  broad  contacts  with  the  teeth  tightly  lodged  together. 
Reference  has  already  been  made  to  the  management  of  the  former 
whereby  a  thin  broad-bladed  instrument  is  forced  between  the 
teeth  and  the  sharp  edges  of  enamel  broken  down,  but  in  many 
of  the  latter  cases  it  is  impracticable  to  force  such  an  instrument 
between  the  teeth.  This  condition  of  worn  facets  on  the  proxi- 
mal surfaces  is  often  associated  with  teeth  the  occlusal  surfaces 
of  which  have  also  been  worn  so  that  the  teeth  present  a  broad, 
flat,  table-like  surface  on  their  occlusal  aspect,  joining  at  a 
sharp  right  angle  the  worn  facet  on  the  proximal  surface.  With 
teeth  of  this  character  presenting  no  V-shaped  depression  or 
slope  from  the  occlusal  surface  to  the  contact  point,  as  in  normal 
cases,  the  problem  of  entering  the  rubber  between  the  teeth  is 
frequently  difficult.  In  every  such  case  the  ligature  should  be 
passed  between  the  contacts  in  advance  of  the  rubber,  to  carry 
away  any  small  particles  of  foreign  material  that  may  be  lodged 
between  the  teeth.     When  the  operator  is  certain  that  all  the 


EXCLUSION    OF    MOISTURE    DURING    OPERATIONS  67 

spaces  are  free  the  dam  should  be  carried  over  the  last  tooth  back 
with  the  clamp,  and  then  the  strip  of  rubber  between  that  tooth 
and  the  one  in  front  of  it  should  be  brought  on  a  stretch  over 
the  contact  points  and  held  there  with  the  fingers  of  the  left  hand, 
one 'finger  forcing  it  down  hard  upon  the  buccal  festoon  of  gum 
and  the  other  upon  the  lingual  festoon.  While  the  dam  is  thus 
hung  up  over  the  junction  of  the  two  teeth,  the  right  hand  may 
be  employed  to  slightly  force  the  teeth  apart  by  passing  the  end 
of  a  thin-bladed  spatula  in  the  interproximal  space  from  the 
buccal  or  labial  aspect,  and  prying  on  the  teeth  with  a  rotary 
movement  of  the  spatula.  This  will  usually  force  the  teeth 
apart  sufficiently  to  allow  the  strip  of  rubber  to  glide  between 
them,  and  the  process  may  be  continued  from  one  contact  point 
to  another  till  all  of  the  teeth  are  embraced  by  the  dam. 

In  every  case  of  difficult  contact  the  passage  of  the  rubber  may 
be  facilitated  by  smearing  the  strips  between  the  holes  with  vase- 
line or  other  suitable  lubricant.  This  will  allow  it  to  glide  more 
readily  past  the  tight  places,  but  care  should  be  exercised  not  to 
allow  any  of  it  to  come  upon  the  surface  of  the  dam  to  be  grasped 
by  the  fingers.  If  by  any  inadvertence  it  gets  on  this  surface  it 
will  instantly  destroy  all  possibility  of  securing  an  adequate  grasp, 
and  it  is  therefore  well  to  dispense  with  it  entirely  except  with 
teeth  presenting  particularly  difficult  contacts. 

Occasionally  the  operator  will  encounter  trouble  in  applying  the 
dam  in  cases  where  the  teeth  themselves  are  not  at  fault,  on  ac- 
count of  muscular  resistance  on  the  part  of  the  patient's  lips  and 
tongue.  Where  this  tendency  is  discovered  in  any  manipulation 
about  the  mouth  it  is  sometimes  advisable  to  hand  the  patient  a 
mirror  and  let  him  watch  the  movements  of  the  tongue  and  lips, 
and  see  to  what  extent  they  are  discommoding  the  operator. 
With  some  patients  this  is  a  sufficient  appeal  to  their  intelligence 
to  result  in  overcoming  the  impulse,  but  with  others  there  seems 
to  be  an  uncontrollable  tendency  to  resist  the  dam.  In  such 
cases,  where  it  is  impossible  to  bring  about  a  relaxation  of  the 
muscles  and  an  acquiescence  on  the  part  of  the  patient,  the 
operator  would  better  Kmit  the  application  of  the  dam  to  as  few 
teeth  as  will  permit  of  reasonable  access  to  the  work.  This 
difficulty  is  ordinarily  confined  more  particularly  to  the  lower 
molars,  and  it  is  usually  advisable  in  such  cases  to  let  the  applica- 
tion of  the  dam  terminate  at  the  first  bicuspid.  To  keep  the  dam 
out  of  the  operator's  way  and  to  hold  it  more  secure  against 


68  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

displacement  from  the  action  of  the  tongue  and  cheek,  it  is 
often  a  most  excellent  plan  to  slip  a  clamp  over  the  first  bicuspid 
with  the  bow  looking  toward  the  front  of  the  mouth.  A  strong 
clamp  should  be  used  for  the  molar,  and,  after  the  rubber  has 
been  carried  to  place  as  best  it  may  till  the  first  bicuspid  is 
reached,  the  bicuspid  clamp  should  be  taken  up  in  the  forceps 
with  the  jaws  looking  away  from  the  forceps,  and  the  clamp 
forced  to  position  on  the  tooth.  The  dam  is  thus  secured  at 
either  extremity  of  its  application,  and  the  operator's  hands  are 
free  to  use  ligatures  and  carry  the  dam  past  the  contact  points 
and  further  perfect  its  adjustment.  This  method  will  often  save 
the  operator  much  annoyance  in  these  stubborn  cases. 

There  are  also  certain  cavities  which,  in  mouths  where  for  any 
reason  the  application  of  the  dam  is  difficult,  may  be  adequately 
protected  by  adjusting  the  dam  to  a  single  tooth.  Small  cavities 
in  the  occlusal  surfaces  of  molars  may  often  be  filled  in  this  way 
if  the  case  presents  peculiar  obstacles  to  the  extension  of  the  dam 
over  other  teeth.  But  the  disadvantages  of  operating  on  a  tooth 
under  such  conditions  render  it  advisable  to  limit  this  practice  to 
the  fewest  possible  number  of  cases. 

The  Use  of  Napkins  and  Cotton  Rolls  for  Maintaining  Dryness 
During  Operations 

In  many  minor  operations,  where  the  time  necessary  for  their 
performance  is  quite  limited,  the  rubber  dam  may  well  be  dis- 
pensed with,  and  the  teeth  kept  dry  by  the  use  of  napkins  or 
cotton  rolls  made  for  this  purpose.  The  upper  teeth  are  more 
easily  managed  in  this  manner  than  the  lower  ones,  but  even  on 
the  lower  jaw  the  skillful  use  of  the  napkin  may  in  many  mouths 
serve  a  useful  purpose.  In  employing  napkins  or  rolls  for  the 
exclusion  of  moisture  consideration  should  be  had  for  the  points 
at  which  the  saliva  enters  the  mouth,  and  an  effort  should  be  made 
to  control  it  as  far  as  possible  at  the  location  of  its  entrance. 
On  the  lower  jaw  the  salivary  ducts  open  into  the  floor  of  the 
mouth  under  the  free  end  of  the  tongue,  or  jus]:  in  front  of  the 
attachment  of  the  tongue  to  the  floor;  while  on  the  upper  jaw 
the  ducts  open  from  the  cheek  opposite  the  buccal  surfaces  of 
the  molar  teeth. 

Napkins 

Napkins  for  this  purpose  are  conveniently  made  from  a  piece 
of  clean  bleached  linen,  cut  to  the  desired  size  and  form  for  the 


EXCLUSION    OF    MOISTURE    DURING    OPERATIONS  69 

case  in  hand,  and  after  being  used  once  should  be  thrown  away. 
To  exclude  moisture  from  the  lower  teeth  a  piece  should  be  cut 
sufficiently  long  to  reach  from  the  lingual  surfaces  of  the  molars 
on  one  side  around  under  the  tip  of  the  tongue  to  the  lingual  sur- 
faces of  the  molars  on  the  other.  It  should  be  wide  enough  so 
that  when  folded  into  a  pad  it  will  be  sufficiently  thick  to  fit  with 
some  pressure  between  the  tongue  and  the  lower  jaw,  but  not  so 
thick  that  the  tongue  is  discommoded  to  the  extent  of  rebelling 
against  it  and  forcing  it  out  of  position.  It  will  thus  be  seen  that 
the  size  must  vary  in  different  mouths. 

To  adjust  this  napkin  it  should  be  grasped  with  the  pliers  near 
one  end,  and  the  patient  instructed  to  raise  the  tongue  toward  the 
roof  of  the  mouth.  This  end  of  the  napkin  should  then  be  car- 
ried down  between  the  side  of  the  tongue  and  the  lower  jaw  be- 
neath the  lingual  surfaces  of  the  molar  teeth  on  one  side,  and  then 
the  napkin  passed  under  the  tip  of  the  tongue  immediately  over 
the  salivary  ducts  and  around  to  the  other  side  of  the  mouth  in  the 
same  way.  The  patient  should  then  be  instructed  to  allow  the 
tongue  to  rest  lightly  on  the  napkin,  but  cautioned  not  to  run  it 
under  the  napkin  and  lift  it.  This  protects  the  lingual  aspect  of 
the  teeth,  but  the  buccal  surfaces  require  attention  to  guard 
against  the  saliva  which  flows  down  the  cheek  from  Steno's  duct. 
If  the  duct  is  located  quite  far  up  on  the  cheek  it  may  be  guarded 
by  packing  a  short  napkin  between  the  cheek  and  the  upper 
teeth,  but  if  the  opening  is  low  the  saliva  is  likely  to  trickle  down 
along  the  cheek  and  reach. the  lower  teeth.  The  only  alternative 
is  to  place  a  plump  napkin  along  the  buccal  surfaces  of  the  lower 
molars  and  bicuspids,  and  hold  it  against  the  cheek  and  gum  with 
the  fingers.  The  saliva  will  of  course  flow  down  from  the  upper 
duct,  but  it  will  be  absorbed  by  the  thick  napkin  and  not  reach 
the  lower  teeth.  If  the  napkin  gets  too  much  saturated,  so  as  to 
endanger  leaking  against  the  teeth,  it  may  be  adroitly  removed 
and  replaced  by  a  dry  one. 

The  late  Dr.  Geo.  E.  Hunt  suggested  a  very  effective  method 
of  employing  the  napkin  to  secure  dryness  and  control  the  tongue 
by  passing  the  napkin  around  under  the  tongue  as  just  indi- 
cated and  then  carrying  one  end  of  it  up  across  the  dorsum  of 
the  tongue  and  with  the  fingers  of  the  left  hand  tightly  com- 
pressing the  napkin  and  tongue  down  over  the  opening  of  the 
ducts.  If  held  firmly  the  tongue,  after  a  preliminary  struggle 
or  two,  will  remain  quiescent,  and  few  patients  will  object  to 


70  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

this    procedure    if    it    is    done   in    a    precise    and    determined 
manner. 

In  most  instances  the  compression  of  the  napkin  over  the  open- 
ings of  the  ducts  will  effectually  stop  all  saliva  from  entering  the 
mouth,  and  under  these  conditions  the  napkin  becomes  adherent 
to  the  dried  mucous  membrane,  and  must  be  removed  with  the 
greatest  caution  through  fear  of  injuring  the  membrane. 

In  excluding  moisture  from  the  upper  teeth  with  the  napkin,  it 
is  necessary  only  to  pack  against  the  opening  of  Steno's  duct  by 
placing  the  napkin  between  the  cheek  and  the  upper  jaw  above 
and  against  the  buccal  surfaces  of  the  molars  and  bicuspids.  To 
prevent  the  patient  from  closing  the  mouth  and  moistening  the 
cavity  with  the  tongue,  a  mouth-mirror  should  invariably  be 
held  as  a  guard  under  the  upper  teeth  in  such  a  way  as  to  protect 
the  operation. 

RoUs 

To  provide  a  more  convenient  means  than  the  use  of  the 
napkin,  cotton  rolls  were  devised  and  placed  on  the  market. 
They  are  furnished  by  the  manufacturers  in  various  sizes,  and  in 
lengths  sufficient  to  enable  the  operator  to  cut  them  to  suit  any 
individual  case.  They  are  effective  for  very  short  operations — 
particularly  upon  the  upper  teeth — but  they  have  not  the  same 
range  of  service  that  has  a  napkin  properly  applied.  It  is  seldom 
that  they  can  be  maintained  in  place  if  passed  from  the  lingual 
surfaces  of  the  molars  on  one  side  of  the  lower  jaw  to  the  molars  on 
the  other  side,  and  their  use  is  therefore  practically  limited  to  one 
side  of  the  mouth.  They  are  not  so  effective  in  guarding  the 
orifices  of  the  ducts  as  are  napkins,  and  must  depend  chiefly 
upon  their  absorptive  properties  for  gathering  up  the  saliva  as 
it  flows  against  them.  But  they  should  be  found  in  every  oper- 
ating case,  on  account  of  their  great  convenience  in  the  limited 
number  of  cases  to  which  they  are  suited,  and  their  range  of 
usefulness  may  be  greatly  extended  by  the  employment  in  con- 
nection with  them  of  a  good  saliva  ejector. 

To  retain  the  rolls  in  place  when  the  tongue  has  a  tendency 
to  toss  them  up,  a  rubber  dam  clamp  may  be  slipped  over  the 
tooth  and  a  small  portion  of  the  roll  caught  between  the  jaw 
of  the  clamp  and  the  tooth.  This  will  effectually  hold  the  rolls 
in  position. 


CHAPTER  V 
CLASSIFICATION  AND  PREPARATION  OF  CAVITIES 

The  following  brief  classification  of  cavities  is  adapted  from  the 
report  of  the  Committee  on  Syllabus  presented  to  the  Institute 
of  Dental  Pedagogics,  and  adopted  by  that  body. 

Cavities,  as  to  character,  are  divided  into  two  general  classes: 
•pit  and  fissure  cavities,  and  smooth  surface  cavities. 

Pit  and  fissure  cavities  are  those  occurring  as  the  result  of 
structural  imperfections  in  the  enamel  due  to  faulty  develop- 
ment, whereby  two  or  more  islands  of  calcification  in  approaching 
each  other  have  failed  to  grow  together  or  coalesce,  leaving  a 
break  in  the  continuity  of  the  enamel-covering.  This  defect 
results  in  the  admission  of  the  micro-organisms  of  decay,  and 
forms  a  harbored  shelter  in  which  they  may  work  their  destruc- 
tive processes  unmolested. 

These  cavities  are  found  in  the  occlusal  surfaces  of  bicuspids 
and  molars,  in  the  lingual  surfaces  of  upper  incisors,  and  in  the 
occlusal  two-thirds  of  the  buccal  and  lingual  surfaces  of  molars. 
It  will  thus  be  seen  that  they  occur  in  surfaces  which  are  ordi- 
narily kept  clean  by  the  friction  of  food  in  mastication  or  by  the 
tongue  or  cheeks,  and  are  therefore  directly  traceable  to  faults 
in  the  enamel-structure. 

Smooth  surface  cavities  are  those  occurring  in  surfaces  where 
the  enamel  is  perfectly  formed,  but  where  the  location  is  such  that 
it  is  not  ordinarily  kept  clean  by  friction.  They  are  thus  dis- 
tinctive in  character  from  pit  and  fissure  cavities,  both  as  regards 
the  conditions  which  bring  them  about  and  the  methods  to  be 
employed  in  their  preparation.  These  distinctions  will  receive 
more  detailed  consideration  later. 

Cavities  under  this  head  occur  in  the  proximal  surfaces,  and  in 
the  gingival  third  of  labial,  buccal,  or  lingual  surfaces. 

Cavities,  as  to  extent  and  location,  are  divided  into  simple  cavi- 
ties and  complex  cavities. 

Simple  cavities  are  those  involving  only  one  surface  of  a  tooth, 
as  an  "occlusal"  cavity,  a  "buccal"  cavity,  a  " labial' '  cavity,  etc. 

71 


72  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

Complex  cavities  are  those  involving  two  or  more  surfaces,  as  a 
"mesio-occlusal"  cavity,  a  "disto-labial"  cavity,  a  "mesio- 
disto-occlusal "  cavity,  etc. 

Cavities  are  named  according  to  the  surfaces  of  the  teeth  in 
which  they  occur,  and  cavity-walls  are  named  according  to  the 
surface  or  anatomical  landmark  toward  which  they  approach. 
Examples. — In  a  mesio-occlusal  cavity  in  an  upper  bicuspid  the 
buccal  wall  is  that  wall  which,  if  extended  far  enough,  would 
involve  the  buccal  surface  of  the  tooth;  the  gingival  is  that  wall 
which,  if  extended  far  enough,  would  involve  the  gingival  line. 
In  an  occlusal  cavity  in  a  lower  molar  the  bottom  or  floor  of  the 
cavity  is  called  the  pulpal  wall,  and  in  case  of  death  of  the  pulp, 
so  as  to  involve  the  pulp-chamber,  the  floor  then  becomes  the  sub- 
pulpal  wall. 

An  axial  surface  of  a  tooth  is  any  surface  parallel  with  the  long 
axis  of  the  tooth,  and  an  axial  wall  is  that  wall  which  approaches 
the  pulp  in  a  cavity  in  an  axial  surface. 

CAVITY  PREPARATION 
Proximal  Cavities  in  Incisors  and  Cuspids 

Simple  Cavities  not  Involving  the  Incisal  Angle. — When  decay 
occurs  in  the  proximal  surfaces  of  any  of  the  anterior  teeth,  we 
are  confronted  with  problems  peculiar  to  the  locality.  The 
first  consideration,  as  in  every  other  class  of  cavities,  is  of  course 
the  preservation  of  the  teeth,  but  in  these  exposed  positions  we 
must  not  ignore  esthetic  and  artistic  effects  if  we  would  do  the 
highest  class  of  service.  Were  it  possible  for  us  to  save  these 
teeth  by  filling  without  advertising  the  fact  to  the  world,  it  would 
be  our  manifest  duty  to  do  so;  but  unfortunately  this  cannot 
always  be  done,  particularly  if  gold  is  used.  It  may  also  be 
stated  that  in  the  attempt  to  hide  our  work  by  confining  our 
gold  fillings  to  narrow  are9,s  we  often  jeopardize  the  teeth  and 
lessen  the  confidence  of  the  public  in  the  permanence  of  dental 
operations  through  recurrence  of  decay  and  consequent  under- 
mining of  the  tooth-structure. 

Observant  operators  have  noticed  that  there  are  certain  points 
around  ordinary  proximal  fillings  where  decay  is  most  likely  to 
recur.  This  relates  in  anterior  teeth  to  the  gingivo-labial,  gin- 
givo-lingual,  and  the  incisal  angles.  The  reason  for  this  is  found 
in  the  fact  that  these  regions  are  not  kept  clean  by  the  friction 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES  73 

of  food  in  mastication,  or  by  the  lips  or  tongue  in  their  various 
movements.  If  the  anatomical  relation  of  the  proximal  surfaces 
of  these  teeth  is  studied,  it  will  be  seen  that  a  considerable  area 
in  the  vicinity  of  the  contact  point  is  not  cleansed  by  the  natural 
processes.  This  is  what  admits  of  caries  in  this  region  in  the 
first  instance.  If  in  the  preparation  of  a  cavity  we  limit  the 
area  to  a  small  round  outline,  we  have  left  unprotected,  at  the 
points  indicated,  more  or  less  of  the  surface  of  enamel  which  is 
still  subject  to  decay.  With  the  same  conditions  present  and  the 
same  influences  at  work  which  originally  induced  decayj  there  is 
little  to  prevent  a  recurrence.  The  remedy  lies  in  so  extending 
the  outlines  of  the  cavity  that  the  margins  are  carried  to  a  point 
where  they  will  be  kept  clean.  This  process  has  been  termed 
"extension  for  prevention"  by  Dr.  G.  V.  Black  and  "extension  for 
immunity"  by  Dr.  E.  K.  Wedelstaedt,  and  its  observance  must 
be  insisted  upon  where  the  most  permanent  work  is  required. 

Another  point  of  frequent  failure  around  these  fillings  is  along 
the  lingual  margin.  This  is  due  to  the  fact  that  the  lingual  wall 
is  often  left  exceedingly  thin,  and  the  enamel  is  crushed  under  the 
stress  of  mastication.  The  force  of  the  lower  incisors  comes  di- 
rectly against  this  surface,  and  any  unprotected  enamel  is  likely 
to  be  broken  down.  In  every  instance  where  possible  the  margin 
should  be  so  extended  as  to  leave  the  enamel  well  supported  by 
dentin,  and  wherever  this  cannot  be  done  the  enamel  should  be 
freely  beveled  and  the  gold  or  other  filling  material  built  over  it 
in  such  a  manner  as  to  protect  it.  Enamel  protected  in  this  way 
with  care  and  skill  will  remain  intact  in  ordinary  positions,  and 
yet  this  does  not  alter  the  general  rule  that  enamel  is  safest  when 
supported  by  dentin. 

Fig.  38  shows  the  proximal  surface  of  an  incisor  with  a  small 
round  filling,  a,  points  of  recurrence  of  decay,  hhb,  and  the  out- 
line to  which  the  cavity  should  be  carried  for  greatest  safety,  c. 

This  question  of  extension  is  a  matter  calling  for  the  most  care- 
ful consideration.  It  is  confidently  believed  to  be  a  solution  of 
the  problem  connected  with  a  very  frequent  form  of  failure  in  this 
class  of  cases,  and  yet  it  must  not  be  employed  indiscriminately. 
There  are  many  cases  where  it  would  be  manifestly  impossible  and 
injudicious  to  cut  the  cavity  to  the  extent  indicated.  Patients 
apply  to  us  for  these  fillings  occasionally  in  such  a  nervous  con- 
dition that  any  extra  cutting  beyond  the  present  necessities  of 
the  case  must  be  avoided.     We  should  never  jeopardize  the  ner- 


74  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

vous  system  of  our  patient  in  order  to  carry  out  some  heroic 
theory.  Then  again,  there  are  persons  in  whose  mouths  the 
tendency  to  caries  is  so  sHght  that  extension  for  prevention  would 
appear  to  be  an  unnecessarily  extreme  measure.  In  some  of 
these  cases  where  there  is  limited  decay,  small  fillings  may  prove 
serviceable  for  years.  The  age  of  the  patient  also  has  an  impor- 
tant bearing  on  the  question.  Whenever  we  find  the  proximal 
surfaces  breaking  down  rapidly  under  decay  early  in  life,  we  may 
infer  that  the  process  of  caries  is  to  be  active  in  that  mouth,  and 
we  must  employ  the  most  strenuous  means  to  control  it.  Ex- 
tension for  prevention  is  here  indicated  to  its  fullest  legitimate 
extent.  But  in  a  patient  well  toward  maturity  with  an  occa- 
sional cavity  developing,  we  may  often  safely  stop  short  of  the 
most  extreme  cutting.  Then  esthetic  reasons  play  an  important 
part  in  the  anterior  teeth.     If  we  can  hide  our  fillings  from  view 


Fig.  39. 

we  should  do  so,  and  many  of  our  patients  are  willing  to  take 
the  chances  of  a  recurrence  of  decay  rather  than  have  large  fillings 
made  in  the  first  instance.  A  distinct  understanding  should  be 
had  with  patients  upon  these  points,  so  that  they  may  enter 
intelligently  into  the  merits  of  the  different  methods.  We 
should  be  sufficiently  honest  with  them  to  proceed  on  the  theory 
that  wherever  these  small  hidden  fillings  are  inserted  the  work 
must  be  considered  more  or  less  temporary,  and  must  be  kept 
under  constant  surveillance  by  the  dentist. 

In  brief,  the  operator's  attitude  toward  the  practice  of  ex- 
tension should  be  to  aim  always  at  the  most  ideal  and  permanent 
form  for  his  cavities,  and  in  every  instance  where  he  deviates 
from  this  it  must  be  only  on  account  of  some  well-defined  reason 
for  doing  so. 

There  is  one  feature  connected  with  the  appearance  of  fillings 
in  the  anterior  teeth  which  must  not  be  overlooked.  As  has  been 
said,  it  is  sometimes  well  to  keep  fillings  from  view  if  possible, 
but  whenever  it  becomes  necessary  for  a  filling  to  show  at  all  it 
should  be  extended  labially,  so  as  to  show  distinctly.     The  reason 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES  75 

for  this  is  that  where  gold  is  placed  between  teeth  in  such  a  way 
that  it  is  in  the  shadow,  the  appearance  a  few  feet  distant  from 
the  patient  is  that  of  a  black  mass  simulating  decay,  while  if  the 
filling  is  carried  out  sufficiently  to  allow  the  rays  of  light  to  reflect 
upon  it  the  bright  yellow  tinge  of  gold  is  immediately  perceptible. 
There  should  therefore  be  very  little  compromise  Vjetween  a 
filling  kept  entirely  out  of  sight,  and  a  good,  bold  showing  of  the 
gold  from  the  labial  aspect.     Figs.  39  and  40  illustrate  this  point. 

The  entire  question  of  the  displa}^  of  gold  in  anterior  fillings 
has  assumed  an  altogether  different  aspect  since  the  introduction 
of  porcelain  inlay  work  and  the  silicate  cements.  By  the  use 
of  these  materials  conspicuous  fillings  may  largely  be  avoided, 
and  in  those  cases  where  esthetic  considerations  are  paramount 
they  may  be  used  to  excellent  advantage.  This  is  not  saying 
that  for  general  utility  they  are  preferable  to  gold  even  in  anterior 
teeth,  but  merely  that  as  a  means  of  enabling  us  to  conceal  our 
art  from  the  public  gaze  they  are  most  useful  adjuncts  to  our 
list  of  filling  materials. 

Separating  Teeth. — -The  first  requirement  in  operating  on  these 
cavities  is  to  have  sufficient  space  between  the  teeth  for  perfect 
access.  This  must  be  obtained  in  some  instances  by  wedging 
previous  to  the  operation,  in  others  space  may  be  gained  while 
operating  by  the  use  of  a  separator.  In  cases  where  the  teeth 
have  fallen  together  to  any  appreciable  extent  as  the  result  of 
deep  proximal  decay,  or  where  the  teeth  overlap  in  a  slight  ir- 
regularity, the  separator  will  ordinarily  not  gain  sufficient  space 
for  a  proper  contour  of  the  filling.  Neither  can  we  gain  access  to 
do  perfect  work  on  small,  hidden  cavities  (in  those  cases  where  it 
may  be  deemed  advisable  to  fill  in  that  manner)  short  of  exten- 
sive separation.  Where  the  labial  or  lingual  wall  is  well  cut 
away,  the  access  is  simplified. 

The  methods  employed  for  gradual  separation  previous  to  op- 
erating may  be  varied  according  to  the  requirements  of  the  case. 
Rubber  has  been  used  for  this  purpose  quite  extensively  in  the 
past,  but  it  is  only  in  the  rarest  cases  where  rubber  is  properly 
indicated.  The  difficulty  with  this  material  lies  in  the  fact  that 
it  cannot  easily  be  maintained  in  position.  The  sloping  surfaces 
of  the  teeth  tend  to  make  it  slide  away  from  the  contact  points 
and  insinuate  itself  into  the  interproximal  space  to  the  serious 
injury  of  the  gum-tissue.  Rubber  should  never  be  used  even  in 
the  extremest  cases  without  previously  protecting  the  gum  by 


76  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

packing  cotton,  gutta-percha,  or  cement  against  the  gingival 
wall  of  the  cavity,  allowing  it  to  extend  across  the  interproximal 
space  to  prevent  the  movement  of  the  rubber  rootwise. 

The  materials  best  adapted  for  separating  are  cotton,  gutta- 
percha, and  linen  tape.  Cotton  should  be  packed  firmly  between 
the  teeth  while  dry,  and  if  there  is  difficulty  in  maintaining 
it  in  position  it  can  be  secured  by  passing  a  ligature  between  the 
teeth  in  the  interproximal  space  before  placing  the  cotton,  and 
then  bringing  the  ends  down  over  it  toward  the  incisal  surfaces 
of  the  teeth  and  tying  tightly  around  the  cotton.  This  holds  it 
securely  in  place  and  proves  a  very  effective  means 
of  separating  teeth.  Fig.  41  illustrates  the  method 
of  tying  the  cotton  in  place. 

Gutta-percha  may  be  employed  by  first  adjusting 

the  separator,  forcing  the  teeth  slightly  apart,  and 

packing  the  gutta-percha  into  the  cavity  and  firmly 

between  the  teeth.      The  separator  is  then  removed  and  the 

gutta-percha   allowed   to  remain  for   several   days.      This  will 

usually  result  in  good  space  without  soreness. 

The  best  method  of  preparing  tape  for  separating  is  to  take 
some  linen  tape  about  four  millimeters  wide  and  soak  it  in  a  thin 
solution  of  chlora-percha,  afterward  letting  the  chloroform  evapo- 
rate from  the  tape.  This  leaves  a  pliable,  tough  and  impervious 
tape,  which  is  almost  unbreakable,  and  which  may  be  left  between 
the  teeth  for  days  without  deteriorating  or  becoming  offensive.  It 
is  really  one  of  the  most  desirable  materials  yet  suggested  for 
separating  teeth,  and  may  be  employed  in  those  cases  where  there 
has  been  little  or  no  breaking  down  of  the  proximal  surfaces,  and 
where  it  would  be  difficult  to  retain  cotton  or  gutta-percha.  By 
either  of  these  methods  the  pressure  is  so  gradual  that  space  is 
gained  without  the  distressing  irritation  which  usually  accom- 
panies the  use  of  rubber. 

In  favorable  instances,  or  in  emergency  cases,  space  may  be 
gained  at  the  time  of  the  operation  by  the  use  of  the  separator. 
Wherever  the  separator  is  indicated  it  should  be  used  in  the  fol- 
lowing way:  Care  must  be  exercised  in  its  adjustment  not  to  allow 
it  to  impinge  on  the  gum  or  unnecessarily  wound  the  soft  tissues. 
It  should  not  be  tightened  to  the  limit  at  once,  but  merely 
"snugged  up"  till  the  patient  feels  it.  Then,  as  the  operation 
progresses,  it  can  be  gradually  tightened  at  intervals  without 
appreciable  discomfort.     By  the  time  the  cavity  is  prepared,  suf- 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES  77 

ficient  space  will  usually  have  been  gained  to  admit  of  the  inser- 
tion and  proper  contouring  of  the  filling,  and  then  a  slightly  addi- 
tional space  obtained  during  this  part  of  the  operation  will  afford 
opportunity  for  polishing.  When  the  filling  is  finished,  the  great- 
est caution  should  be  observed  in  removing  the  separator.  If  it 
is  loosened  suddenly  after  being  tightened  to  the  extent  usually 
necessary,  it  will  result  in  most  excruciating  pain  to  the  patient, 
the  discomfort  from  this  source  ordinarily  being  greater  than  from 
the  process  of  separating.  It  should  be  loosened  very  gently 
and  slowly  till  the  contact  between  the  filling  and  the  tooth  next 
in  line  is  sufficient  to  hold  the  teeth  from  further  movement. 

In  manipulating  the  separator  the  greatest  delicacy  of  touch 
should  at  all  times  be  exercised.  It  is  a  dangerous  and  cruel  ap- 
pliance in  the  hands  of  the  thoughtless  or  careless.  The  operator 
should  invariably  employ  one  hand  to  steady  the  bows  while  the 
other  tightens  the  screws,  to  prevent  tilting  or  shifting  the  sepa- 
rator. Any  rocking  or  twisting  of  the  appliance  will  result  in 
unnecessary  pain,  and  undue  injury  to  the  soft  parts.  Another 
serious  limitation  to  the  separator  lies  in  the  danger  to  enamel- 
margins  when  the  jaws  impinge  close  to  the  cavity.  The  enamel 
may  thereby  be  checked  in  such  a  way  as  to  jeopardize  the  useful- 
ness of  the  filling  without  the  operator's  observation  of  the  fact  at 
the  time.  Cases  for  the  separator  should  be  selected  with  care 
and  judgment,  and  due  consideration  for  the  patient  must 
invariably  accompany  its  use.  With  these  precautions,  it  is 
really  a  humane  appliance  and  is  capable  of  a  large  range  of 
usefulness.  It  is  not  only  indicated  for  gaining  space  between 
teeth,  but  may  frequently  be  used,  where  space  has  already  been 
obtained,  for  the  purpose  of  holding  the  teeth  firm  during  the 
operation.  This  avoids  in  large  measure  any  soreness  from 
malleting,  and  also  prevents  the  teeth  from  gradually  dropping 
together  while  the  filling  is  being  inserted. 

Wooden  wedges  may  also  be  used  occasionally  for  this  purpose, 
but  the  difficulty  with  wooden  wedges  lies  in  the  fact  that  they  are 
usually  injurious  to  the  gum-tissue  in  the  interproximal  space,  and 
their  entire  wedging  force  must  be  exerted  immediately  instead  of 
gradually.  Whenever  a  wooden  wedge  is  used  to  hold  the  teeth 
firm  during  an  operation  it  should  be  made  as  narrow  as  possible, 
and  the  rubber  dam  should  be  stretched  well  labially  before  the 
wedge  is  inserted,  to  overcome  the  tendency  which  the  dam  other- 
wise would  have  of  dragging  the  wedge  out  of  place. 


78  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

Detail  of  Cavity  Formation 

After  frail  enamel-walls  have  been  broken  down  and  the  mar- 
gins extended  to  the  desired  outline,  all  decay  should  be  removed 
and  the  cavity  given  such  form  that  the  filling  will  be  retained 
securely  in  place. 

The  Gingival  "PFa^^.— This  wall  should  be  extended  rootwise  suf- 
ficiently to  carry  the  margin  of  the  filling  well  under  the  gum  in 
accordance  with  Fig.  38.  The  line  d  represents  the  gum  as  it 
comes  down  between  the  teeth  in  the  interproximal  space,  and  the 
outline  of  the  filling  c  shows  the  gingival  portion  overlapped  by 
the  gum.  The  reason  for  this  extension  is  the  well-known  fact 
that  wherever  we  have  the  gingival  portion  of  a  perfectly  in- 
serted filling  covered  by  healthy  gum-tissue,  we  will  never  have 
recurrence  of  decay  at  that  point.  In  cases  where  the  enamel 
has  begun  to  take  on  a  whitened  appearance  at  the  gum-margin 
extending  gingivo-labially  and  gingivo-lingually  from  the  cavity, 
thus  indicating  an  approaching  disintegration,  or  where  the 
activity  of  the  carious  process  seems  to  be  very  great  in  that 
mouth,  the  gingival  outline  of  the  cavity  should  be  carried  well 
out  gingivo-labially  and  gingivo-lingually  as  illustrated  in  Fig.  42. 
This  gives  the  gingival  outline  a  curve  with  its  convexity  toward 
the  cavity. 

The  gingival  margin  of  proximal  fillings  has  often  been  alluded 
to  as  the  "vulnerable  point,"  even  when  fillings  were  well  inserted, 
but  this  is  hardly  in  strict  accordance  with  facts.  In  reality 
decay  seldom  recurs  along  the  gingival  margin  proper.  It 
usually  begins  at  the  gingivo-labial  (or  buccal)  and  gingivo- 
lingual  angles.  From  here  it  may  extend  and  involve  the  entire 
gingival  margin,  but  the  initial  point  of  failure  is  usually  at  the 
angles.  This  is  because  there  is  a  lodgment-place  in  these 
positions  for  deleterious  matter  to  form  undisturbed  by  friction 
from  the  tongue  or  lips,  and  unprotected  by  gum-tissue.  In 
this  small  sheltered  harbor  the  micro-organisms  of  caries  produce 
their  acid  and  attack  the  enamel.  No  tooth  may  be  considered 
safe  from  recurrence  of  decay  around  proximal  fillings  unless  the 
gingival  wall  has  been  carried  sufficiently  rootwise  to  bring  that 
portion  of  the  filling  under  the  gum,  and  the  gingivo-labial  and 
gingivo-lingual  angles  have  been  extended  to  a  point  where  these 
margins  of  the  filling  are  kept  clean  by  friction. 

This  form  of  extension  results  in  the  gingival  wall  being  either 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES 


79 


flat  labio-lingually  or  convex  toward  the  cavity,  and  this  is  be- 
lieved to  be  desirable  for  other  reasons  than  those  of  prevention. 
A  filling  is  more  easily  built  upon  a  flat  base  than  upon  a  curved 
base,  and  is  more  secure  from  dislodgment  when  completed. 
The  prevailing  custom  of  forming  the  gingival  wall  on  a  curve 
labio-lingually  so  as  to  be  concave  toward  the  cavity  is  account- 
able for  the  fact  that  many  operators  find  their  fillings  rocking 
when  partly  inserted,  and  it  has  also  led  to  the  necessity  of 
drilling  pits  more  or  less  deep  (and  more  or  less  disastrous)  in  the 
gingival  portion  of  the  cavity. 


Fig.  42. 


Fig.  43. 


Fig.  44. 


Fig.  45. 


To  subserve  the  best  ends  in  anchorage  the  gingival  wall  should 
also  be  made  flat  mesio-distally,  with  a  slight  incline  rootwise  as 
the  gingival  wall  approaches  the  axial  wall  (Fig.  43).  In  some 
instances  this  incline  may  take  the  form  of  a  shallow  groove  in  the 
dentin  extending  from  the  gingivo-labial  to  the  gingivo-lingual 
angles  of  the  cavity,  and  carried  somewhat  into  the  lingual  wall 
at  this  point  to  facilitate  the  starting  of  the  filling.  It  should  not 
be  carried  to  any  extent  into  the  labial  wall,  on  account  of  the 
difficulty  of  adapting  gold  into  an  inaccessible  undercut  such  as 
this  would  be. 

The  Lingual  Wall. — As  has  already  been  intimated,  this  waU 
should  be  freely  cut  away  if  frail.  The  temptation  to  leave  it  for 
the  purpose  of  having  something  to  build  the  gold  against  in  the 
insertion  of  the  filling  has  proved  the  stumbling-block  of  many  an 
operator.  If  sufficiently  supported  by  dentin  it  need  not  be  ex- 
tended farther  than  is  necessary  for  prevention,  but  in  some  in- 
stances it  must  be  cut  away  nearly  on  a  line  with  the  axial  wall. 
Especially  is  this  true  in  those  cases  where  for  esthetic  reasons 
it  is  considered  desirable  to  leave  the  labial  wall  standing  and 
insert  the  filling  mostly  from  the  lingual  aspect.     The  difficulty 


80  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

of  doing  a  perfect  and  permanent  operation  in  this  way 
renders  these  cases  rare,  and  limits  them  sharply  to  cavities 
having  a  strong  labial  wall. 

When  the  lingual  wall  is  cut  away  freely,  the  only  attempt  at 
retention  along  this  wall  should  be  as  it  approaches  the  gingivo- 
axial  angle  and  the  incisal  angle.  Here  a  right  angle  may  be  made 
with  the  axial  wall,  or  in  the  gingival  extremity  of  the  lingual  wall 
the  groove  previously  mentioned  in  the  gingival  wall  may  be  di- 
verted at  right  angles  into  the  gingival  third  of  the  lingual  wall. 
This  not  only  aids  in  retention,  but  provides  a  cul-de-sac  into 
which  may  readily  be  secured  the  first  pieces  of  gold.  Deep 
grooving  should  generally  be  avoided  in  these  cavities  on  account 
of  the  uncertainty  of  gaining  perfect  adaptation  and  density  of  the 
gold  in  the  bottom  of  grooves,  and  also  because  of  the  con- 
sequent weak  walls  to  the  cavity;  but  in  the  gingivo-lingual 
region  these  objections  are  not  strictly  operative.  Direct  access 
may  be  gained  with  a  plugger,  and  the  bulk  of  tooth-tissue 
covering  the  pulp  at  this  point  admits  of  judicious  grooving 
without  creating  weak  walls.  But  in  no  instance,  even  where  it 
is  deemed  advisable  to  leave  the  lingual  wall  standing,  should  the 
groove  be  extended  throughout  the  length  of  the  wall.  The 
most  that  should  be  done  in  the  middle  third  of  the  wall  is  to 
make  more  or  less  of  an  angle  between  that  and  the  axial  wall. 

The  Labial  Wall. — The  same  general  rules  apply  to  the  formation 
of  this  wall  that  have  just  been  outlined  for  the  lingual  wall, 
except  that  grooving  is  contraindicated  in  any  portion  of  its  length. 
In  cases  where  possible  an  angle  may  be  formed  with  the  axial 
wall  to  increase  the  security  of  anchorage,  and  especially  should 
this  be  done  in  the  gingival  and  incisal  thirds. 

The  Incisal  Angle. — This  should  be  formed  at  right  angles  with 
the  axial  wall  (Fig.  43).  It  should  never  be  deeply  grooved, 
nor  should  a  pit  be  drilled  at  this  point,  as  is  frequently  done.  To 
assist  in  retention  of  the  filling  it  may  be  slightly  inclined  toward 
the  incisal  edge  of  the  tooth  as  it  approaches  the  axial  wall. 

The  Axial  Wall. — The  form  of  the  other  walls  practically  deter- 
mines the  shape  of  this  wall.  It  should  be  as  nearly  as  possible  at 
right  angles  with  the  others,  leaving  in  all  cases  as  much  dentin 
covering  the  pulp  as  is  consistent  with  strength  of  the  filling  and 
a  thorough  removal  of  all  decay. 

The  Enamel-Margins. — The  final  step  in  the  preparation  of  the 
cavity  is  the  treatment  of  the  margins.     The  enamel  should  be  so 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES  81 

beveled  that  the  peripheral  ends  of  the  rods  are  cut  off  and  the 
dentinal  ends  covered  with  gold  when  the  filling  is  inserted. 
This  calls  to  mind  the  necessity  for  introducing  two  terms  to 
properly  designate  enamel-margins.  In  reality  there  are  two 
margins  to  enamel,  and  in  cavities  such  as  we  are  considering  a 
clear  distinction  between  the  two  is  important.  There  is  the 
enamel-margin  at  the  periphery  of  the  tooth,  and  the  enamel- 
margin  next  to  the  dentin.  For  want  of  better  terms  these  may 
be  designated  the  'peripheral  enamel-margin,  and  the  dento- 
enamel-margin  (Fig.  44,  a  and  b). 

If  in  all  cases  the  enamel  could  be  left  well  supported  for  con- 
siderable depth  by  dentin  the  distinction  in  terms  would  not  seem 
so  important,  but  this  is  not  always  possible;  and  where  such  is 
the  case  the  treatment  of  these  two  margins  is  dissimilar.  The 
peripheral  margin  should  be  given  a  distinct  bevel,  while  the 
dentinal  margin  should  be  slightly  rounded. 

The  necessity  for  beveling  enamel  relates  to  the  peculiarity  of 
its  structure.  It  is  composed  of  rods  standing  with  their  ends  on 
the  dentin  and  radiating  out  toward  the  periphery  of  the  tooth  in 
a  more  or  less  regular  manner.  The  enamel  when  supported  by 
dentin,  and  with  no  break  in  the  continuity  of  its  structure,  will 
sustain  great  stress  without  fracture,  but  when  undermined  by 
decay  it  is  easily  broken  down.  This  break  is  usually  in  line  with 
the  enamel-rods,  which  indicates  that  the  cement-substance 
holding  the  rods  together  is  not  very  strong.  If,  then,  the 
peripheral  ends  of  the  rods  are  left  standing  around  a  filling  while 
the  dentin  is  gone,  and  possibly  the  dentinal  ends  of  the  rods  dis- 
solved out  by  caries  or  burred  away  in  the  preparation  of  the 
cavity,  it  is  readily  seen  that  the  short  peripheral  rods  must 
sooner  or  later  drop  out,  even  if  they  escape  crushing  in  the  inser- 
tion of  the  gold  (Fig.  45).  This  admits  of  a  leak  around  the 
filling.  To  make  perfect  margins  the  enamel  should  be  so 
beveled  that  there  are  no  short  rods  at  the  periphery.  But  this 
bevel  must  not  be  too  acute,  nor  must  the  peripheral  margin  be 
rounded.  Either  of  these  conditions  would  result  in  the  filling- 
material  assuming  too  attenuated  a  form  at  the  edges,  which 
would  admit  an  element  of  weakness  to  the  filling.  The  exact 
degree  of  bevel  cannot  well  be  given  in  figures,  owing  to  the 
variation  necessary  in  the  different  locations  along  cavity- 
margins  on  account  of  the  varying  direction  of  the  enamel-rods. 
The  degree  of  bevel  must  largely  be  governed  by  the  direction  of 


82  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

the  rods  in  each  particular  locality,  and  the  only  way  to  determine 
this  short  of  a  microscopical  examination,  which,  of  course,  is  im- 
practicable in  the  mouth,  is  by  the  sense  of  touch.  The  opera- 
tor's fingers  may  be  so  schooled  that  in  trimming  the  enamel  with 
a  sharp  chisel  he  can  readily  determine  the  arrangement  of  the 
rods  by  the  ease  with  which  the  enamel  is  cleaved  in  certain 
directions.  Remembering  that  the  enamel  cleaves  most  readUy 
in  line  with  the  direction  of  the  rods,  he  is  able  to  intelligently 
judge  the  condition  of  the  margia  by  the  manner  in  which  the 
blade  affects  it,  and  so  long  as  the  peripheral  portion  of  the  enamel 
breaks  down  readily,  or  is  easily  pulverized,  the  trimming  must 
continue.  This  delicate  "feeling"  along  the  margins  of  cavities 
with  a  sharp  instrument  is  very  necessary  to  the  establishment 
of  a  perfect  outline,  and  is  the  only  true  criterion  as  to  the  degree 
of  bevel  indicated  in  each  given  case. 

In  every  instance  where  the  dento-enamel-margin  is  at  all 
prominent  it  should  be  slightly  rounded,  as  already  indicated,  to 
facilitate  the  perfect  adaptation  of  the  gold  against  it.  (Fig.  46, 
a,  peripheral  enamel-margin  beveled,   b   dento-enamel  margin 


Fig.  46.  Fig.  47. 

rounded,  c  filling-material  protecting  margin.  In  this  cut  the 
rounded  margin  h  is  too  prominent,  making  too  long  a  bevel 
and  too  thin  a  margin  to  the  gold  at  a.  It  should  be  more  like 
Fig.  47.) 

The  marginal  outlines  of  these  cavities  should  represent  sym- 
metrical and  graceful  curves  that  will  not  offend  the  eye  of  the 
artist.  In  the  formation  of  the  walls  of  the  cavity,  angles  have 
been  recommended  at  various  points  for  the  firm  retention  of  the 
filling,  but  angles  are  never  permissible  along  the  margins  for 
esthetic  reasons.  As  the  gingival  margin  joins  the  labial  or 
lingual  margin  it  should  not  be  at  a  sharp  angle,  but  on  a  curve. 
This  curve  may  in  some  instances  be  rather  short,  but  it  must 
invariably  be  a  symmetrical  and  definite  curve  (Figs.  38  and 
42).  The  outlines  along  the  labial  and  lingual  walls  should  be 
true  and  clearly  cut  to  present  the  most  artistic  appearance. 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES  83 

The  dentist  should  aim  not  only  to  do  serviceable  operations, 
but  to  do  beautiful  ones  as  well. 

Technique. — The  first  step  in  the  operation  is  to  break  down  un- 
supported enamel-margins.  This  may  best  be  done  with  suitably 
formed  chisels,  made  sharp.  In  some  instances  the  thin  over- 
hanging labial  wall  may  be  cleaved  away  to  advantage  with  a 
short,  strong  hatchet  excavator.  The  blade  must  not  be  long 
enough  to  penetrate  into  the  cavity  sufficiently  to  expose  the  pulp 
or  impinge  on  sensitive  dentin  as  the  enamel  is  broken  in.  Care 
should  be  exercised  especially  in  the  early  stages  of  the  opera- 
tion not  to  shock  the  patient.  A  false  movement  at  this  time 
will  do  much  to  unnerve  the  average  individual.  If  it  is  found 
necessary  to  give  pain  in  an  operation,  it  is  best  if  possible  to 
defer  that  particular  part  of  the  work  till  the  patient  has  been 
some  minutes  in  the  chair.  It  will  ordinarily  then  be  better 
tolerated. 

After  weak  walls  are  broken  down  the  cavity  should  be  ex- 
tended to  its  proper  outlines.  This  can  usually  be  done  rapidly 
and  effectively  with  sharp  burs,  either  round  or  oval,  as  the  case 
demands.  In  the  use  of  burs  for  this  purpose — or  in  fact  for 
any  purpose- — ^due  regard  must  be  exercised  for  maintaining  the 
bur  precisely  at  the  angle  and  in  the  position  required.  No 
operator  should  venture  to  use  an  instrument  like  the  dental 
engine  without  previously  having  acquired  an  absolute  control 
of  the  hand-piece,  and  having  studied  carefully  its  dangers  and 
limitations  as  well  as  its  legitiriiate  uses.  The  failure  of  operators 
to  properly  manipulate  the  engine  is  accountable  for  much  of  the 
prejudice  against  it.  The  principal  dangers  to  be  guarded  against 
in  extending  these  proximal  cavities  in  incisors  relate  to  the  dis- 
placement of  the  bur  by  catching  the  blades  against  the  margins 
of  enamel  and  carrying  the  bur  either  into  the  cavity  or  out 
across  the  surface  of  enamel.  To  prevent  this  the  hand-piece 
should  be  firmly  grasped  and  the  bur  applied  to  the  margin 
without  too  much  force,  and  at  such  an  angle  that  it  may  be 
maintained  in  position. 

If  the  cavity  is  one  which  looks  toward  the  operator,  the  bur 
may  be  held  at  right  angles  with  the  long  axis  of  the  tooth, 
and  in  that  position  it  is  not  likely  to  slip.  In  cavities  looking 
away  from  the  operator  where  the  position  of  the  bur  is  more 
nearly  parallel  with  the  long  axis  of  the  tooth,  the  shank  of  the 
bur  should  have  a  bearing  on  the  surface  of  the  enamel  in  such 


84  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

a  way  that  the  bur  will  be  braced  against  displacement  while 
the  blades  are  playing  along  the  margins. 

After  the  cavity  has  been  extended  to  the  desired  outlines  the 
decalcified  dentin  should  be  removed.  This  is  ordinarily  best 
done  with  thin,  sharp  excavators,  though  in  some  instances  the 
same  bur  which  extended  the  outlines  may  be  used  for  a  few  revo- 
lutions to  remove  the  diseased  tissue.  In  those  cases  where  the 
decay  has  penetrated  to  any  extent,  this  work  should  be  done  with 
spoon  excavators  to  avoid  needless  pulp-exposure.  An  instru- 
ment with  a  sharp  angle,  as  in  the  hatchets  and  hoes,  is  more 
likely  to  penetrate  too  far  and  puncture  the  pulp  than  one  with 
a  rounded  form  such  as  the  spoons. 

When  the  carious  tissue  is  removed  the  walls  should  be  shaped 
for  anchorage.  For  the  gingival  wall  an  inverted  cone  bur  of 
suitable  size  should  be  placed  with  its  end  against  this  wall, 
and  the  shank  as  nearly  as  may  be  parallel  with  the  long  axis  of 
the  tooth.  It  is  then  carried  labially  and  lingually  along  the 
gingival  wall  till  the  proper  form  is  secured.  The  end  of  the  bur 
leaves  the  gingival  wall  flat,  and  produces  nearly  a  right  angle 
between  the  gingival  and  axial  walls.  This  angle,  while  not 
strictly  speaking  a  right  angle  (unless  the  bur  is  held  perfectly 
parallel  with  the  tooth),  is  sufficiently  so  for  practical  purposes, 
and  the  form  left  by  the  bur  presents  a  surface  parallel  with  the 
end  of  the  plugger  point,  thus  facilitating  the  adaptation  of  the 
gold  against  this  wall.  In  cases  where  necessary  the  gingival 
wall  may  be  slightly  grooved  with  the  bur,  but  in  every  instance 
it  must  be  used  with  care  and  judgment  to  avoid  too  deep  cutting 
and  pulp-exposure. 

As  the  bur  reaches  the  gingivo-linguo-axial  angle  of  the  cavity 
it  may  be  withdrawn  crownwise  along  the  gingival  third  of  the 
lingual  wall,  making  a  slight  groove  at  this  point  as  before  advo- 
cated. This  groove  formed  by  the  side  of  the  bur  will  be  rounded. 
If  deemed  advisable  it  may  be  squared  out  with  an  excavator  to 
an  angle  with  the  axial  wall. 

The  labial  wall  is  formed  by  placing  the  inverted  cone  bur  with 
its  end  against  the  axial  wall  and  its  shank  at  right  angles  with  the 
long  axis  of  the  tooth.  By  carrying  the  bur  laterally  along  the 
labial  wall  from  the  gingival  wall  to  the  incisal  angle  the  side  of 
the  bur  will  give  form  to  the  labial  wall,  and  an  angle  will  be 
created  between  that  and  the  axial  wall. 

The  incisal  angle  of  the  cavity  may  be  formed,  in  cases  where 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES  85 

there  is  suitable  access,  by  carrying  the  inverted  cone  bur  down 
into  this  angle,  cutting  side  wise,  with  its  end  facing  the  axial  wall. 
The  form  of  the  Vjur  gives  the  required  angle  between  the  incisal 
and  axial  walls.  Where  the  bur  cannot  be  placed  in  the  proper 
position  to  accomplish  this  purpose,  the  incisal  angle  may  be 
formed  with  small,  delicate  excavators,  and  in  the  entire  forma- 
tion of  the  cavity  indications  may  point  to  the  use  of  excavators 
instead  of  burs.  It  is  believed  that  with  sharp  burs  carried  in  a 
hand-piece  under  perfect  control  more  effective  cutting  can  be 
made  in  a  given  time  than  with  hand  instruments,  and  yet  the 
operator  must  not  lose  sight  of  the  advantages  of  excavators 
under  certain  conditions,  nor  enslave  himself  to  the  prejudiced 
following  of  any  one  method  under  all  circumstances.  He  should 
study  the  mechanical  and  the  nervous  requirements  of  the 
case,  and  readily  adapt  himself  to  the  most  serviceable  plan  of 
procedure. 

The  enamel  margins  may  be  beveled  with  a  fine-bladed  round 
bur  used  in  the  manner  advocated  for  cavity  extension,  or  they 
may  be  planed  off  with  delicate  sharp  chisels,  as  the  casa 
indicates. 

General  Considerations 

It  may  be  noted  that  some  of  the  suggestions  here  advanced 
relative  to  cavity  formation  appear  somewhat  radical  when  com- 
pared with  the  methods  generally  in  vogue  in  the  profession. 
The  advocacy  of  angles  between  the  walls  of  these  cavities  may 
impress  many  as  being  illogical  and  impracticable  in  view  of  the 
orthodox  teaching  on  the  subject.  Curved  outlines  to  cavity- 
walls  have  usually  been  suggested  whenever  there  has  been  any 
suggestion  at  all.  This  has  been  done  with  a  view  of  making  a 
cavity  into  which  the  filling-material  might  easily  be  adapted, 
and  one  of  the  first  objections  likely  to  be  urged  against  the  forma- 
tion of  angles  is  the  supposed  difiiculty  of  adapting  gold  into 
such  angles.  This  question  of  the  non-adaptability  of  gold  to 
angles  has  been  much  overdrawn.  It  is  simply  a  matter  of  proper 
manipulation,  with  pluggers  of  a  suitable  form  to  carry  the  gold 
into  the  angle.  It  need  not  here  be  stated  that  a  plugger  with  a 
round  shank  and  a  flat  serrated  face  is  not  the  form  for  this 
purpose. 

Gold  can  easily  and  accurately  be  adapted  into  a  sharp  right 
angle,  as  has  repeatedly  been  proved  by  experiment.     The  advan- 


86  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

tages  of  making  angles  in  cavities  relate  to  the  ease  with  which 
fillings  may  be  started  in  such  cavities,  and  the  unquestioned 
security  of  anchorage  without  undermining  and  weakening  the 
walls.  Fillings  built  upon  flat  bases  have  a  greater  stability 
against  displacement  under  stress  than  those  built  upon  curved 
bases,  and  the  gold  is  less  likely  to  rock  during  its  insertion. 

It  will  be  found  that  in  the  practical  application  in  the  mouth  of 
the  methods  here  advocated  it  is  seldom  that  a  perfectly  sharp 
angle  is  made  in  one  of  these  cavities,  especially  in  any  position 
where  it  is  at  all  difficult  to  fill.  The  principle  involved  is 
merely  the  formation  of  flat  walls  instead  of  curved  walls,  and 
the  operator  who  makes  the  trial  of  building  fillings  against 
flat  walls  after  being  accustomed  to  curved  walls  will  not  long 
remain  in  doubt  as  to  which  is  the  preferable  method.  There 
is  a  sense  of  security  to  the  work  as  it  progresses  which  is  never 
experienced  when  the  walls  have  been  formed  in  curves. 

Fig.  47  shows  a  longitudinal  section  of  a  tooth  mesio-distally, 
with  cavity  formed  and  filled.  It  will  be  seen  that  the  filling  is 
mortised  or  dovetailed  into  place,  with  no  deep  grooves  or  under- 
cuts to  weaken  the  walls. 

Proximal  Cavities  in  Anterior  Teeth  Involving  the  Incisal  Angle 

When  caries  has  progressed  so  far  that  the  proximo-incisal  angle 
is  either  broken  down  or  so  undermined  that  it  is  unsafe  to  leave 
it,  the  problem  of  anchorage  becomes  correspondingly  com- 
plicated. With  this  angle  gone  and  the  consequent  necessity  for 
its  reproduction  in  gold  or  other  material  an  additional  area  of 
filling  is  exposed  to  stress  tending  to  its  dislodgment.  The  usual 
plan  of  anchoring  these  fillings  has  been  to  groove  the  gingival 
wall  deeply,  with  additional  grooves  along  the  labial  and  lingual 
walls  wherever  possible,  and  then  drill  for  anchorage  in  the  incisal 
region  between  the  lingual  and  labial  plates  of  enamel  as  they 
approach  each  other  near  the  incisal  edge  (Fig.  48). 

While  many  fillings  anchored  in  this  manner  have  stood  the 
test  for  years,  and  while  there  are  some  instances  in  which  this  is 
the  only  practical  method  of  anchorage,  it  is  confidently  believed 
that  for  the  majority  of  cases  there  is  a  better  and  safer  means  at 
hand.  The  limitations  of  this  method  relate  to  the  fact  that  any 
tipping  stress  upon  such  a  filling  has  a  tendency  to  lift  it  away 
from  its  incisal  anchorage,  and  either  loosen  it  entirely,  or  so 
dislodge  it  as  to  cause  a  leak  along  the  incisal  half  of  its  outline 
(Fig.  49). 


CLASSIFICATION   AND    PREPARATION    OF    CAVITIES  87 

To  more  securely  anchor  these  fillings  at  their  incisal  extremi- 
ties, it  is  recommended  to  create  a  step  at  right  angles  with  the 
main  body  of  the  filling  by  cutting  a  groove  along  the  incisal  edge, 
or  rather  by  cutting  away  the  incisal  portion  of  the  lingual  plate 
of  enamel  to  a  sufficient  depth  and  length  to  gain  strength  of 
filling-material.  The  labial  plate  of  enamel  is  ordinarily  left 
standing  for  appearance,  so  that  while  more  gold  is  used  in  this 
kind  of  a  fiUing,  the  excess  is  presented  to  the  lingual  aspect  of 
the  tooth,  Fig.  50,  and  there  is  no  greater  exposure  of  gold  to  the 
labial  aspect  than  in  the  ordinary  contour  filling.  The  advantage 
of  this  form  of  anchorage  must  appeal  to  every  mechanical  mind. 


Fig.  48.         Fig.  49.         Fig.  50.         Fig.  51.  Fig.  52.         Fig.  5.3. 

A  filling  properly  placed  in  such  a  cavity  cannot  be  dislodged 
short  of  fracture  of  the  filling  or  stretching  of  the  gold  from 
repeated  impacts  of  the  lower  tooth  at  the  point  where  the  main 
body  of  the  filling  joins  the  step.  Stress  brought  to  bear  on 
such  a  filling  in  the  process  of  biting  has  a  tendency  to  force  the 
filling  into  the  cavity  instead  of  lifting  it  away,  as  in  the  usual 
methods  of  anchorage. 

Detail  of  Cavity  Formation 

The  same  general  plan  of  formation  is  followed  in  the  gingival 
third  of  the  cavity  that  was  advocated  for  simple  proximal 
cavities,  except  that  the  anchorages  may  be  made  deeper,  and  if 
possible  broader,  for  the  contour  filling. 

The  Labial  Wall. — -This  wall  should  be  formed  as  nearly  as  possi- 
ble at  definite  right  angles  with  the  axial  wall.  The  creation  of 
an  angle  at  this  point  is  a  matter  of  importance  in  all  cases  where 
the  extent  of  the  labial  wall  will  permit  it.  The  direction  of  stress 
against  these  fillings  by  the  lower  incisors  is  often  obliquely  up- 
ward and  toward  the  labial  (Fig.  51),  and  the  broader  we  can 
make  the  area  of  resistance  to  this  stress  the  more  securely  will  we 
retain  the  filling.     The  open  aspect  of  these  cavities  renders  the 


88  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

adaptation  of  gold  into  such  an  angle  very  convenient.  The 
labial  wall  of  the  step  should  have  the  same  form  and  same  angle 
between  it  and  the  seat  of  the  step  or  pulpal  wall.  This  portion 
of  the  labial  wall  should  be  left  as  thick  as  possible  to  prevent 
the  gold  from  showing  through  and  to  represent  considerable 
strength.  In  those  teeth  where  the  incisal  edge  is  so  thin  that 
there  is  no  opportunity  for  leaving  an  adequate  labial  plate  it  may 
be  necessary  to  shorten  the  labial  wall  somewhat  and  build  the 
gold  over  it  so  as  to  expose  it  to  view  from  the  labial  aspect  (Fig. 
52).  In  such  a  procedure  artistic  appearance  is  sacrificed  for 
safety. 

In  every  instance  where  this  wall  is  left  standing,  it  should  be 
beveled  as  illustrated  in  Fig.  53,  and  the  gold  built  over  the  bevel 
with  the  greatest  care.  Protected  in  this  way,  it  is  often  possible 
to  retain  this  wall  with  safety,  and  thus  disguise  our  operation  to 
that  extent. 

In  considering  the  strength  of  this  wall  an  objection  may  be 
urged  by  some  against  the  formation  of  an  angle  to  the  cavity  at 
the  junction  of  the  labial  with  the  other  walls,  on  the  mechanical 
ground  that  whenever  a  fracture  occurs  it  is  more  likely  to  locate 
itself  at  an  angle  than  at  any  other  place.  In  view  of  the  fact  that 
the  present  system  of  cavity  preparation  involves  the  formation  of 
angles  at  different  points  in  the  depths  of  cavities,  it  may  be  well 
to  consider  this  matter  at  this  time. 

If  we  stop  to  study  the  causes  of  fractured  walls,  we  shall  see 
that  they  are  due  either  to  the  fact  that  the  walls  have  been  left 
unprotected  by  gold,  or  that  the  gold  has  so  shifted  from  its 
original  position  in  the  cavity  as  to  bring  undue  stress  upon  the 
wall.  If  we  protect  the  wall  with  gold  and  the  gold  remains 
firm,  there  will  be  no  fracture.  The  question  arises  how  to 
maintain  the  gold  securely  against  movement.  According  to  the 
most  approved  and  logical  mechanical  principles,  this  is  best 
solved  by  building  it  against  flat  walls  joined  by  angles,  rather 
than  against  circular  walls  joined  by  curves.  Other  things  being 
equal,  gold  will  shift  under  stress  just  in  proportion  as  the  base 
upon  which  it  rests  is  rounded.  It  is  simply  the  difference  be- 
tween attempting  to  roll  a  cube  and  a  sphere. 

But  aside  from  this,  those  who  have  been  led  to  fear  fractured 
walls  on  account  of  making  angles  in  cavities  need  not  hesitate 
on  this  score,  because  in  the  mouth  it  will  be  found  practically  im- 
possible to  form  an  angle  so  sharp  or  so  acute  that  it  will  deter- 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES  89 

mine  the  location  of  a  fracture — even  if  a  fracture  should  occur. 
The  attempt  to  make  angles  insures  more  fully  the  general  plan 
of  flat  surfaces,  and  is  recommended  mainly  for  that  purpose.  It 
is  firmly  believed  that  the  ideal  cavity  should  have  flat  walls 
joined  by  definite  angles,  forming  a  mortise  for  the  filling-material, 
but  it  is  exceedingly  difficult  to  attain  the  ideal  in  the  mouth. 

As  has  already  been  stated,  these  angles  should  be  confined  to 
the  interior  of  the  cavity,  and  when  the  exposed  outlines  are 
formed  they  should  be  given  symmetrical  curves  for  esthetic  rea- 
sons. In  accord  with  this  the  margin  of  the  labial  wall  of  the 
cavities  under  consideration  should  execute  a  short  curve  from  the 
proximal  to  the  incisal  rather  than  have  an  abrupt  angle  at  that 
point  (Fig.  54). 

The  Lingual  Wall. — This  wall  should  be  cut  freely  away  in  the 
incisal  region  to  admit  of  sufficient  bulk  of  gold  to  represent  con- 
siderable strength  to  the  filling  as  the  proximal  joins  the  incisal 
portion.  This  is  essentially  the  weak  point  of  these  fillings,  any 
breaking  or  stretching  of  the  gold  resulting  in  a  lifting  away  of  the 
,  proximal  portion  of  the  filling. 

This  wall  should  be  given  some  retentive  form  to  maintain  the 
filling  against  possible  force  from  the  labial  aspect  in  the  form  of 
accidental  blows.  This  can  usually  be  accomplished  in  the 
gingival  third  of  the  wall  and  at  the  extremity  of  the  step  if  no 
other  opportunity  presents  itself  (Fig.  50a,  b). 

The  Step. — The  length  of  the  step  mesio-distally  must  be  deter- 
mined by  the  requirements  of  the  case.  It  should  be  extended  far 
enough  to  firmly  anchor  the  filling,  and  in  those  cases  where  the 
incisal  edge  of  the  enamel  has  been  worn  down  so  as  to  expose 
the  dentin  the  step  should  be  carried  across  the  tooth  to  include 
all  exposed  dentin.  It  should  be  made  sufficiently  deep  pulpally 
to  admit  of  strength  to  the  gold,  but  not  far  enough  to  endanger 
the  pulp.  Its  width  labio-lingually  must  be  governed  somewhat 
by  the  thickness  of  the  tooth,  and  in  those  cases  where  necessary 
the  lingual  plate  may  be  cut  away  freely  to  add  to  the  width  of 
the  step. 

The  base  of  the  step,  or  pulpal  wall,  should  be  made  perfectly 
flat.  This  is  one  of  the  most  important  considerations  in  the 
kind  of  cavity  formation  under  discussion.  If  the  pulpal  wall  is 
rounded  in  the  least  degree,  it  materially  lessens  the  stability  of 
the  incisal  portion  of  the  filling.  The  limited  area  presented  for 
the  reception  of  the  gold  at  this  point  imposes  upon  us  the  ne- 


90  PRINCIPLES    AND    PRACTICE    OP    FILLING    TEETH 

cessity  for  maintaining  the  greatest  possible  security  to  a  given 
bulk  of  material,  and  this  can  only  be  done  by  building  the  gold 
against  a  perfectly  flat  surface.  This  wall  should  also  be  ex- 
tended slightly  into  the  dentin  pulpally  as  it  approaches  the  ter- 
mination of  the  step  (Fig.  50a) .  This  is  to  add  to  the  security  of 
the  filling  against  the  tipping  stress.  As  the  step  terminates,  it 
should  end  in  an  abrupt  wall  parallel  with  the  long  axis  of  the 
tooth  and  at  a  right  angle  with  the  pulpal  wall. 

Technique. — The  same  general  plan  of  technique  may  be  fol- 
lowed as  was  advocated  for  simple  proximal  cavities  up  to  the 
formation  of  the  step.  To  form  the  step  an  inverted  cone  bur 
should  be  placed  with  its  side  against  the  incisal  third  of  the  axial 
wall,  as  illustrated  in  Fig.  55,  and  carried  laterally  into  the  tissue 
to  the  extent  required  for  the  length  of  the  step — the  cutting 
being  done  with  the  side  of  the  bur.  This  leaves  the  desired 
flat  base  to  the  step.  The  projecting  lingual  plate  of  enamel 
left  by  the  bur  can  readily  be  broken  down  with  chisels. 


Fig.  54.  Fig.  55.  Fig.  56. 

The  labial  and  lingual  enamel-margins  can  best  be  beveled 
with  small  sand-paper  disks  in  the  engine,  provided  the  operator 
studies  carefufly  their  proper  use.  The  disk  must  be  held  at  such 
an  angle  as  to  give  a  distinct  bevel.  Any  rocking  or  tipping  of 
the  disk  will  result  in  a  rounding  of  the  peripheral  enamel-margin, 
the  disadvantage  of  which  has  already  been  mentioned.  The 
enamel  at  the  termination  of  the  step  can  be  beveled  with  a 
round  bur. 

General  Considerations 

Two  items  of  detail  must  be  carefully  observed  to  make  this 
method  of  cavity  .preparation  of  the  highest  esthetic  value.  The 
labial  wall  must  be  left  as  thick  as  possible  to  avoid  the  reflection 
of  the  gold  through  the  enamel,  and  the  gold  must  be  adapted 
accurately  to  this  wall  throughout.  If  there  is  any  failure  of 
perfect  adaptation,  the  filling  will  eventually  leak  at  this  point, 
giving  rise  to  an  unsightly  discoloration  under  the  enamel.     The 


CLASSIFICATION    AND    PREPARATION    OP    CAVITIES  91 

most  delicate  and  precise  placing  of  the  gold  and  the  highest  de- 
gree of  density  possible  are  necessary  for  perfect  results.  When 
these  are  attained,  it  is  confidently  believed  that  this  method 
will  prove  very  serviceable  in  a  certain  class  of  cases  which  have 
in  the  past  been  troublesome  to  many  operators. 

The  contraindications  to  this  method  relate  to  cases  where  the 
lingual  wall  has  been  extensively  disintegrated  by  caries,  thus  de- 
stroying the  possibility  of  making  a  step  anchorage.  Usually 
such  cases  involve  the  pulp,  and  wherever  the  pulp  is  removed,  an- 
chorage may  be  obtained  if  necessary  by  cementing  a  strong 
iridio-platinum  post  into  the  pulp-chamber  and  allowing  it  to 
extend  toward  the  incisal  portion  of  the  cavity  in  such  a  manner 
that  the  gold  can  be  built  around  it  and  the  filling  retained  in 
position  (Fig.  56).  No  one  method  is  universally  applicable 
to  these  cases  any  more  than  to  other  cavities,  and  the  operator 
who  would  attain  the  best  results  must  carefully  study  each  case 
that  presents  and  be  prepared  to  apply  the  particular  method 
indicated  in  that  especial  case.  The  most  that  can  be  taught  are 
principles  and  plans,  and  he  who  cannot  apply  his  individual 
ingenuity  to  meet  the  requirements  of  special  cases  ought  never 
to  have  been  a  dentist. 

The  question  may  arise  with  some  as  to  the  advisability  of  in- 
serting these  large  contour  fillings  instead  of  crowning  the  teeth; 
in  fact,  we  see  occasional  doubts  thrown  upon  contour  operations 
since  crown-work  has  become  so  common.  It  must  always  re- 
main a  matter  of  the  nicest  discrimination  just  when  to  abandon 
filling  and  substitute  crowning,  but  it  may  be  laid  down  as  a  safe 
axiom  that  a  tooth  presenting  sufficient  material  to  maintain  a 
filling  for  a  reasonable  period  should  be  filled.  Sometimes  these 
extensive  operations  will  last  many  years,  and  when  the  final 
crash  comes  and  the  filling  is  lost,  the  tooth  presents  the  same 
opportunities  for  crowning  that  it  did  before  it  was  filled.  In 
filling  a  doubtful  tooth  we  extend  the  serviceability  of  that  tooth 
just  the  number  of  years  the  filling  lasts.  In  other  words,  the 
crown  is  likely  to  remain  in  service  as  many  years  after  the  filling 
has  failed  as  it  would  have  done  had  it  been  employed  in  the  first 
instance.  It  is  therefore  sometimes  advisable  to  fill  these  in- 
cisors, even  when  both  mesial  and  distal  incisal  angles  are  gone, 
and  to  produce  a  filling  such  as  is  illustrated  in  Fig.  57a,  labial 
aspect,  h,  lingual  aspect. 

The  objections  often  urged  against  these  extensive  fillings  on 


92  PRINCIPLES    AND    PRACTICE    OP    FILLING    TEETH 

the  ground  of  their  excessive  weariness  and  nervous  tax  to  the 
patient  are  rapidly  being  discounted  by  the  fact  that  since  the 
advent  of  inlay  work  we  may  employ  this  method  of  meeting 
these  large  restorations  and  not  subject  the  patient  to  any  ap- 
preciable stress.  The  slight  modifications  in  cavity  preparations 
for  foil  fillings  and  for  inlays  will  be  noted  later  in  the  general 
consideration  of  inlays. 

Proximal  Cavities  in  Bicuspids  and  Molars 

The  principles  involved  in  the  treatment  of  caries  occurring  in 
the  proximal  surfaces  of  bicuspids  are  so  similar  to  those  occur- 
ring in  like  surfaces  of  molars  that  they  will  be  considered  as  one 
class  of  cavities.  Minor  differences  in  the  detail  of  the  work  will, 
it  is  true,  be  called  for,  but  these  are  readily  suggested  by  the 
differences  in  the  forms  of  the  teeth.  The  position  and  function 
of  bicuspids  and  molars  are  nearly  identical,  and  they  are  subject 
to  practically  the  same  influences  leading  to  decay  primarily  and 
to  a  recurrence  of  decay  around  fillings.  The  same  forces  are  at 
work  to  dislodge  fillings,  and  the  same  general  plan  of  anchorage 
must  be  pursued  in  the  one  as  in  the  other.  For  these  reasons 
they  are  treated  in  common. 

Simple  Proximal  Cavities  not  Involving  Other  Surfaces 

The  instances  are  very  rare  where  it  may  be  deemed  advisable 
to  fill  this  kind  of  a  cavity.  Usually  when  decay  begins  in  the 
proximal  surface  of  a  bicuspid  or  molar,  the  proper  preparation 
of  the  cavity  involves  its  extension  through  to  the  occlusal  surface. 
Almost  the  only  exceptions  relate  to  those  cases  where  the  cavity 
faces  an  open  space  caused  by  the  loss  of  a  tooth,  or  to  those  occa- 
sional instances  where  there  has  been  extensive  recession  of  the 
gums  in  the  interproximal  space  and  consequent  decay  in  the 
gingival  region.  This  latter  usually  occurs  in  advanced  age, 
when  such  extensive  cutting  as  would  be  necessary  to  involve  the 
occlusal  surface  would  not  be  justifiable,  and  where  the  open 
interproximal  space  admits  of  access  from  the  buccal  aspect. 
The  farther  rootwise  the  decay  occurs  the  stronger  the  argument 
for  filling  without  extending  occlusally,  on  account  of  the  better 
facility  for  approach  and  the  greater  thickness  of  the  occlusal 
wall. 

But  in  ordinary  caries  occurring  near  the  contact  point,  and 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES  93 

with  the  teeth  standing  in  line  one  against  the  other,  the  rule 
should  be  to  open  the  cavity  to  the  occlusal  surface.  The  reasons 
for  this  lie  in  the  fact  that  in  such  cases  access  cannot  be  gained 
to  do  perfect  work  short  of  very  extensive  separation,  and  then 
when  the  teeth  have  been  so  separated  and  filled,  and  have  fallen 
back  to  their  original  position,  an  element  of  danger  to  the  filling 
remains  on  account  of  the  margin  of  the  filling  being  too  near  the 
contact  point.  The  reason  that  decay  begins  in  this  locality  in 
the  first  instance  is  because  a  certain  area  of  the  tooth-substance 
is  left  exposed  to  the  action  of  micro-organisms,  undisturbed  by 
friction  of  the  tongue,  cheeks,  the  tooth-brush,  or  of  food  in  the 
process  of  mastication.  If  the  line  between  enamel  and  filling 
be  left  near  the  contact  point,  the  same  influences  which  induced 
the  original  decay  may  be  expected  to  act  on  the  enamel  at  the 
margin  of  the  filling  to  bring  about  a  recurrence.  If  the  cavity 
is  extended  occlusally  far  enough  to  make  a  clean  margin,  the 
occlusal  wall  is  thereby  rendered  too  weak  to  withstand  mastica- 
tion. All  operations  performed  upon  these  surfaces  without 
extension  must  therefore  be  considered  in  the  light  of  temporary 
work. 

Sometimes  such  fillings  do  good  service  through  the  care  with 
which  they  are  inserted,  coupled  with  the  probable  fact  that  just 
at  this  time  the  patient  acquires  a  partial  or  complete  immunity 
from  caries.  Many  indifferent  operations  have  received  credit 
for  being  perfect  owing  to  this  very  fact  of  immunity,  and,  as  has 
already  been  intimated,  the  whole  question  of  periodical  immunity 
and  susceptibility  of  our  patients  in  regard  to  the  attack  or  pro- 
gress of  dental  caries  should  receive  more  careful  consideration 
than  it  does.  But  what  concerns  us  now  in  treating  the  present 
subject  is  that  clinical  experience  proves  most  of  these  small 
fillings  to  be  temporary,  and  resort  should  be  had  to  their  occa- 
sional insertion  with  this  fact  clearly  in  mind. 

The  plan  of  anchorage  for  such  fillings  is  very  simple.  There 
is  little  stress  to  dislodge  the  filling,  and  all  that  is  necessary 
in  the  formation  of  the  cavity  is  to  make  parallel  walls  surround- 
ing it  at  right  angles  with  the  axial  wall,  and  to  bevel  the  enamel- 
margins. 

Proximo -Occlusal  Cavities  in  Bicuspids  and  Molars 

Wherever  decay  has  so  invaded  the  proximal  surface  as  to  in- 
volve the  occlusal  surface,  or  wherever  it  is  deemed  necessary  to 


94  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

open  the  cavity  to  the  occlusal  surface  in  those  cases  presenting 
with  this  wall  still  remaining,  a  new  class  of  conditions  confronts 
the  operator.  In  view  of  the  fact,  as  already  intimated,  that 
most  proximal  cavities  in  these  teeth  must  be  made  to  include  the 
occlusal  surface,  it  becomes  necessary  to  study  somewhat  care- 
fully the  conditions  governing  the  treatment  of  such  cases. 

The  principal  objects  to  be  attained  in  the  insertion  of  this 
kind  of  a  filling  are,  first,  to  check  the  existing  decay;  second,  to 
prevent,  so  far  as  possible,  a  recurrence  of  decay  in  the  future; 
third,  to  securely  anchor  the  filling  against  displacement  from  the 
stress  of  mastication;  and,  fourth,  to  so  restore  the  original  form 
of  the  tooth  that  it  will  be  maintained  in  its  proper  relation  with 
the  other  teeth  and  with  the  gum-tissue  filling  the  iaterproximal 
space. 

The  first  of  these  requirements  may  be  met  by  simply  removing 
the  decay  and  inserting  a  filling  with  perfect  margins;  and  this 
would  seem  to  be  the  limit  of  attainment  with  many  operators. 
A  failure  to  recognize  other  necessities  in  the  case  is  accountable 
for  much  of  the  disappointment  following  these  operations, 
through  the  temporary  nature  of  such  a  line  of  work. 

The  same  general  rules  of  extension  for  prevention  apply  to 
these  cavities  that  were  given  for  proximal  cavities  in  the  an- 
terior teeth,  except  that  in  bicuspids  and  molars  esthetic  con- 
siderations do  not  so  materially  affect  the  case,  and  the  rules  may 
therefore  be  less  frequently  waived  on  this  account.  The  usual 
points  of  recurrence  of  decay  around  these  fillings  are  at  the 
gingivo-buccal  and  gingivo-lingual  angles  of  the  cavity,  though  in 
cavities  left  very  narrow  bucco-lingually  the  entire  buccal  and 
lingual  margins  may  become  involved. 

Another  form  of  failure,  where  cavities  are  narrow  in  the  region 
of  the  marginal  ridge,  relates  to  a  fracture  of  the  enamel  at  the 
proximo-occlusal  angles.  Enamel  left  in  this  form  is  easily 
broken  down  by  the  stress  of  mastication,  causing  a  break  be- 
tween the  filling  and  the  margin.  Fig.  58  illustrates  a  bicuspid 
with  a  narrow  filling  a,  points  of  recurrence  of  decay  h  h,  and  of 
fractured  enamel  c  c.  The  line  d  indicates  extension  to  avoid 
these  forms  of  failure. 

The  plan  of  anchorage  for  these  fillings  calls  for  careful  con- 
sideration along  the  lines  of  the  most  approved  mechanical  princi- 
ples, and  with  a  due  regard  for  the  location  of  the  filling  and  the 
probable  stress  to  which  it  will  be  subjected  in  the  process  of  mas- 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES  95 

tication.  The  force  of  mastication  varies  greatly  in  different 
individuals,  and  the  intelligent  operator  will  take  cognizance  of 
this  and  govern  his  operations  thereby. 

In  estimating  the  probable  durability  of  a  filling  and  the  extent 
of  anchorage  required  to  maintain  it  in  place,  a  careful  study 
should  be  made  of  the  landmarks  of  mastication  in  the  mouth  un- 
der treatment.  The  expression  "landmarks  of  mastication"  is 
coined  for  the  purpose  of  directing  attention  to  this  form  of  study. 
Mastication  leaves  its  marks  plainly  and  indelibly  upon  the  teeth 
and  upon  fillings  placed  in  them,  and  these  markings  offer  a  good 
index  for  the  observant  operator  to  estimate  the  probable  average 
force  exerted  in  ordinary  mastication  in  a  given  mouth.  The 
use  of  the  gnathodynamometer  for  the  purpose  of  recording  the 
stress  of  mastication,  while  very  valuable  for  scientific  study  and 
for  throwing  much  light  on  the  possible  force  of  mastication,  is 
not  considered  to  be  the  most  reliable  index  to  the  force  actually 
employed  in  the  comminution  of  food.  The  greatest  possible 
force  that  can  be  exerted  in  closing  the  jaws  is  often  far  removed 
from  the  actual  force  used  in  mastication  in  the  same  mouth,  and 
is  not  invariably  relative  to  it.  For  this  reason,  if  we  accept  it  as 
our  sole  guide  for  the  extent  of  anchorage  required  for  our  fill- 
ings, we  shall  in  some  instances  subject  our  patients  to  unneces- 
sarily broad  and  painful  cutting  to  accomplish  an  object  which 
might  have  been  attained  by  less  heroic  means.  On  the  other 
hand,  we  may  sometimes  fall  short  of  adequate  anchorage  in 
those  cases  where  the  gnathodynamometer  gives  a  low  record,  but 
where  the  actual  wear  and  tear  on  fillings  in  mastication  is  some- 
what severe. 

It  is  true  we  should  aim  in  all  cases  to  anchor  our  fillings  in 
such  security  that  the  greatest  possible  stress  of  which  the  jaws 
are  capable  will  not  dislodge  them,  but  the  conditions  under 
which  we  are  compelled  to  operate  will  not  invariably  permit  it. 
The  requisite  bulk  of  tooth-tissue  is  not  always  left  for  us  by  the 
carious  process,  and  the  sensibilities  of  our  patient  must  also  be 
considered.  The  same  statement  is  true  here  which  was  used  in 
connection  with  cutting  cavities  in  anterior  teeth,  that  we  must 
not  jeopardize  the  nervous  system  of  our  patient  to  follow  out 
some  heroic  theory.  The  fact  of  ignoring  the  patient  in  these 
matters  by  a  blind  pursuit  of  an  ideal  in  the  mind  of  the  operator 
is  accountable  for  much  of  the  aversion  experienced  against 
the  dental  chair,  and  we  must  have  a  care  not  to  discourage 


96  PEINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

people  against  permitting  dental  service  to  be  done  for  them  by 
too  great  a  degree  of  severity  during  the  operation.  This  does 
not  imply  that  we  must  be  slip-shod  in  our  methods,  or  that  we 
must  at  all  times  avoid  giving  pain.  It  is  occasionally  necessary 
to  give  pain,  but  the  operator  should  carefully  study  his  patient 
and  limit  the  discomfort  to  a  reasonable  degree  of  tolerance. 
(This  matter  will  be  considered  more  in  detail  in  a  subsequent 
chapter  on  the  treatment  of  sensitive  dentin.) 

The  landmarks  of  mastication  relate  to  worn  surfaces  of  enamel 
at  points  of  occlusal  contact  which  are  evidently  formed  by  me- 
chanical wear  instead  of  by  erosion,  to  deep  indentations  in 
fillings  made  by  repeated  and  vigorous  thrusts  of  the  opposing 
cusp,  and  occasionally  to  fractured  and  jagged  enamel  showing 
evidence  of  rough  usage.  If  the  operator  will  give  a  careful 
study  to  the  condition  of  his  patients'  teeth  and  watch  for  these 
markings  he  will  soon  be  able  to  tell  quite  accurately  the  prob- 
able degree  of  service  which  a  given  set  of  teeth  are  called  upon 
to  do  at  table,  and  it  will  often  guide  him  in  his  methods  of  an- 
choring fillings. 

The  different  plans  of  anchorage  for  these  proximo-occlusal 
fillings  in  bicuspids  and  molars  deserve  careful  consideration. 
The  method  almost  universally  employed  in  the  past  has  been  to 
cut  a  groove  along  the  buccal  and  lingual  walls  of  the  cavity, 
and  in  some  instances  to  groove  the  gingival  wall.  Anchorage 
in  the  buccal  and  lingual  walls  may  sometimes  be  obtained  where 
the  tipping  stress  is  not  great  and  where  the  occlusal  enamel  is  so 
formed  that  the  cavity  does  not  lead  into  a  fissure.  If  there  is 
little  stress  on  such  a  filling  and  the  gingival  wall  is  made  flat, 
buccal  and  lingual  anchorage  may  suffice.  The  limitations  of  this 
method  relate  to  the  insecurity  of  such  anchorage  against  heavy 
stress,  and  to  the  danger  of  weakening  the  walls  particularly  in 
those  cases  where  the  buccal  and  lingual  outlines  of  the  cavity 
are  sufficiently  extended  for  safety  against  recurrence  of  decay. 
Unless  the  grooves  are  broad  and  deep — a  condition  disastrous 
to  cavity-walls — any  appreciable  tipping  stress  on  such  a  filling 
will  tend  to  lift  it  slightly  away  from  the  axial  wall,  leaving  a 
leak  along  the  filling  at  that  point.  Then,  again,  the  occlusal 
aspect  of  this  form  of  filling  is  ordinarily  unsatisfactory. 

In  bicuspids  especially  the  filling  usually  encounters  a  fissure 
running  mesio-distally  between  the  cusps,  and  leaving  at  the 
junction  of  the  filling  and  fissure  a  shoulder  on  the  filling  impos- 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES  97 

sible  of  perfect  finish,  and  an  element  of  weakness  in  the  prob- 
able recurrence  of  decay  along  the  fissure.  As  has  already  been 
stated,  a  fissure  is  invariably  a  defect  in  the  tooth  whereby  two 
islands  of  calcification  have  failed  to  coalesce  in  its  development, 
leaving  a  break  in  the  continuity  of  the  enamel  at  that  point 
and  a  crevice  for  the  ingress  of  deleterious  matter.  It  should 
therefore  be  the  constant  rule  that  whenever  a  cavity  in  the 
occlusal  surface  of  a  tooth  encounters  a  fissure,  the  fissure  should 
be  drilled  out  to  its  extreme  end  and  included  in  the  cavity. 
What  would  appear  in  most  cases  to  be  a  much  preferable 
method  of  anchorage  to  that  just  considered,  and  one  offering 


Fig.  58. 

greater  security  to  the  filling,  is  to  create  a  step  in  the  occlusal 
surface  of  the  tooth  at  right  angles  with  the  proximal  portion  of 
the  cavity,  and  extending  sufficiently  into  the  occlusal  surface  to 
effectively  lock  the  filling  in  place.  This  also  results  in  the  ob- 
literation of  the  fissure  and  the  formation  of  a  filling  easy  of 
finish.  Fig.  59  shows  the  occlusal  surface  of  a  bicuspid  with  the 
original  cavity  a — the  form  left  by  many  operators — h  the 
fissure,  and  c  the  line  of  extension. 

With  this  form  of  anchorage  the  filling  cannot  be  displaced 
short  of  a  fracture  of  the  filling  or  a  stretching  of  the  material  at 
the  point  where  the  proximal  portion  joins  the  occlusal,  through 
repeated  impacts  of  the  opposing  cusp  in  mastication.  To  pre- 
vent this  the  cavity  should  be  made  deep  enough  at  this  point 
to  allow  of  sufficient  bulk  of  filling-material  for  strength,  and  the 
material  should  be  thoroughly  packed  and  well  condensed  to 
give  it  the  greatest  degree  of  resisting  power. 

The  treatment  of  the  cusps  of  opposing  teeth  coming  against 
these  fillings  is  a  matter  of  much  importance,  particularly  with 
bicuspids.  When  the  sharp  buccal  cusp  of  a  lower  bicuspid 
impinges  so  far  into  a  cavity  in  the  opposing  upper  bicuspid  as  to 
necessitate  making  the  filling  too  thin  for  strength,  or  where  it 
passes  so  far  between  the  cusps  of  the  upper  tooth  as  to  form  a 

7 


98 


PRINCIPLES   AND    PRACTICE    OF   FILLING    TEETH 


wedge  capable  of  splitting  the  tooth,  the  tip  of  the  cusp  on  the 
lower  bicuspid  should  be  ground  down  so  as  to  shorten  it  and 
present  a  broad  surface  to  the  upper  tooth  instead  of  a  wedge 
shape.  This  will  result  in  the  formation  of  a  thicker  and  stronger 
filling  in  the  decayed  tooth,  and  such  a  change  in  the  direction  of 
force  exerted  by  the  lower  tooth  as  to  minimize  the  danger  of 
splitting  its  opponent.  (Fig.  60,  wedge-shaped  lower  bicuspid; 
Fig.  61,  cusp  ground  off,  and  filling  left  stronger  in  opposing 
tooth.)  With  a  wedge-shaped  cusp  there  is  much  lateral  force 
exerted  buccally  and  lingually  against  the  cusps  of  the  upper 
tooth,  but  with  a  broad,  flattened  cusp  the  direction  of  force  is 
more  nearly  parallel  with  the  long  axis  of  the  tooth  and  the 


Fig.  60. 


Fig.  61. 


tendency  to  split  is  lessened.  This  grinding,  if  done  judiciously, 
will  not  interfere  with  the  usefulness  nor  impair  the  integrity  of 
the  lower  bicuspid.  The  enamel  is  very  thick  at  that  point, 
and  there  is  little  liability  to  decay,  so  that  this  method  should 
be  employed  quite  extensively  for  the  greater  permanence  of  our 
fillings  and  the  greater  safety  of  the  teeth,  especially  in  those 
cases  where  the  cusps  of  the  lower  teeth  are  very  prominent  and 
sharp. 

This  matter  is  too  frequently  overlooked  by  operators  even  after 
their  attention  has  been  called  to  it,  with  the  result  that  very 
many  upper  bicuspids  have  been  split  or  fractured  needlessly. 
On  examining  a  set  of  teeth  the  relation  of  the  buccal  cusps  of  the 
lower  bicuspids  to  the  depression  in  the  upper  bicuspids  should  be 
carefully  noted,  and  in  every  case  where  there  is  danger  of 
splitting  the  upper  tooth  the  conditions  should  be  explained  to 
the  patient  and  the  lower  cusp  ground. 


CLASSIFICATION   AND    PREPARATION    OF    CAVITIES  99 

The  Interproximal  Space  and  the  Contact  Point 

One  of  the  most  important  considerations  in  the  management 
of  these  proximo-occlusal  cavities  relates  to  the  form  of  the  filling 
on  the  proximal  surface.  It  should  be  so  built  out  to  a  contour 
that  the  tooth  will  be  maintained  in  its  proper  position  in  the  arch^ 
and  that  the  gum-tissue  in  the  interproximal  space  shall  be  pro- 
tected and  preserved  in  a  healthy  condition.  When  the  teeth 
stand  in  their  normal  relation  in  the  jaws  they  are  supported  on 
their  proximal  surfaces  by  contact  with  the  tooth  next  in  line, 
and  the  interproximal  space  between  these  points  of  contact  and 
the  border  of  the  alveolar  process  is  filled  with  gum-tissue.  This 
gum-tissue  has  an  arched  form  bucco-lingually,  with  the  crest  of 
the  arch  near  the  contact  point;  and  this  form  facilitates  the 
cleansing  of  the  space  by  a  deflection  of  the  food  buccally  and  lin- 
gually  in  mastication.  So  long  as  the  contact  points  are  small  and 
the  space  of  normal  form  and  filled  with  gum-tissue,  foreign  ma- 
terial will  not  find  a  lodgment  in  the  space.  In  the  comminution 
of  fibrous  food,  such  as  meat,  the  fibers  may  occasionally  be 
forced  between  the  contact  points,  but  they  are  not  retained  there 
on  account  of  the  narrowness  of  contact.  The  next  passage  of 
food  on  closure  of  the  jaws  in  being  squeezed  out  buccally  and  hn- 
gually  along  the  incline  of  gum  will  catch  them  and  carry  them 
with  it,  leaving  the  space  clean. 

When  decay  takes  place  in  the  proximal  surface  and  the  con- 
tact point  breaks  down,  the  teeth,  lacking  proximal  support,  have 
a  tendency  to  drop  together,  forcing  the  gum  from  between  them 
and  narrowing  the  space.  In  cases  of  extensive  caries  the  teeth 
may  so  change  their  position  as  to  practically  obliterate  the  space 
and  crush  out  all  of  the  gum-tissue,  leaving  the  buccal  and  lingual 
festoons  of  the  gum  more  prominent  than  that  portion  midway 
between  the  teeth.  This  results  in  an  inverted  arch  to  the  gum, 
and  produces  a  pocket  between  the  teeth  which  is  especially  favor- 
able to  the  reception  and  retention  of  food  debris.  Fig.  62  illus- 
trates the  proximal  surface  of  a  sound  lower  molar  with  the  gum 
covering  it  in  a  normal  arched  form;  Fig.  63,  a  similar  case,, 
with  proximal  decay  and  an  inverted  arch  to  the  gum,  forming 
a  pocket.  When  caries  occurs  in  this  way  the  necessary  pro- 
cedure to  restore  the  gum  to  health  is  to  wedge  the  teeth  apart  to 
their  original  position,  and  then  to  so  contour  the  filling  that  they 
will  be  maintained  there. 


100  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

If  the  filling  is  inserted  without  this  precaution  the  result  is  a 
broad,  flat  proximal  surface  to  the  filling,  which  will  catch  fibers 
of  food  and  retain  them  to  decompose.  This  wedging  of  food 
between  teeth  is  an  element  of  great  discomfort  to  the  patient, 
and  a  proHfic  source  of  failure  in  these  proximal  fillings.  It  not 
only  results  in  recurrence  of  decay,  but  sadly  impairs  the  health  of 
the  gum  and  pericemental  membrane.  It  has  been  conserva- 
tively estimated  that  from  eighty  to  ninety  per  cent,  of  the  pyor- 
rhea pockets  occurring  between  the  teeth  have  been  started  by  the 
irritation  of  food  particles  lodged  in  the  interproximal  spaces 
through  faulty  contact.     In  the  examination  of  a  set  of  teeth 


Fig.  62.         Fig.  63.  Fig.  64.  Fig.  65. 

close  attention  should  be  paid  to  any  food  particles  which  may  be 
found  packed  between  the  teeth,  and  in  every  instance  where 
this  condition  exists,  whether  the  patient  has  been  conscious  of  it 
or  not,  the  matter  should  be  remedied.  No  operation  should  be 
considered  satisfactory  which  does  not  include  in  its  performance 
a  due  regard  for  the  form  of  the  interproximal  space  and  the  health 
of  the  gum-tissue  within  it. 

The  attempt  to  prevent  food  from  wedging  between  teeth  by 
making  broad  contacts  built  tightly  against  the  proximating  tooth 
usually  fails  in  its  object  through  the  fact  that  contact  cannot 
in  this  way  be  made  so  perfect  that  at  times  the  individual  move- 
ment of  the  teeth  one  against  the  other  will  not  result  in  the 
passage  of  fibrous  food  between  them.  When  it  once  makes  its 
way  between  the  filling  and  the  proximating  tooth,  it  is  firmly 
held  there  by  the  broad  contact.  The  only  safe  form  to  give  these 
fillings  is  to  make  a  narrow  rounded  contact,  sufficiently  dense  to 
maintain  the  teeth  in  position  and  to  preserve  its  form  against  the 
wear  occasioned  by  the  individual  movement  of  the  teeth.  This 
wear  is  sometimes  quite  severe,  as  is  shown  by  the  facets  worn  in 
the  enamel  on  the  proximal  surfaces  of  many  sound  teeth.  This 
recalls  the  fact  that  these  worn  facets  are  often  a  prolific  source  of 
discomfort  to  the  patient,  even  where  there  is  no  decay;  and  in 
those  cases  where  a  filling  is  being  built  in  a  cavity  proximating 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES  101 

a  tooth  with  an  extensive  facet,  the  margins  of  the  facet  should  be 
sHghtly  rounded  off  to  produce  an  oval  form  to  the  surface.  The 
attention  of  the  operator  should  not  be  limited  to  the  single  tooth 
being  filled,  but  he  should  study  carefully  the  adjacent  parts,  to  the 
end  that  the  teeth  and  gums  in  the  entire  region  be  placed  in  the 
best  possible  condition.  There  are  even  some  cases  where 
broad  facets  have  been  worn  and  the  teeth  are  slightly  loose  in  the 
arch,  with  food  lodging  between  them,  where  it  is  excellent 
practice  to  cut  a  cavity  in  a  sound  tooth,  wedge  the  teeth  well 
apart,  and  bui  d  a  filling  out  to  a  rounded  contact.  The  wedging 
of  these  teeth  apart  will  tighten  up  the  contacts  on  the  other 
teeth  in  this  vicinity  and  improve  the  integrity  of  the  whole 
arch  on  that  side. 


Fig.  66.  Fig.  67. 

Fig.  64  shows  the  buccal  surfaces  of  two  lower  bicuspids  and 
the  first  molar.  There  is  no  decay  between  the  bicuspids,  and  the 
contact  is  normal  and  gum  healthy.  Between  the  second  bicuspid 
and  first  molar  decay  has  taken  place  in  both  proximal  surfaces, 
allowing  the  teeth  to  fall  together  and  obliterate  the  space.  The 
congested  buccal  festoon  of  gum  is  shown  opposite  the  original 
position  of  the  space.  Fig.  65  illustrates  the  same  two  teeth  when 
wedged  apart  and  contour  fillings  made  to  reproduce  the  inter- 
proximal space.  The  gum-tissue  is  seen  reoccupying  the  space 
in  a  normal  condition.  Fig.  66  represents  the  occlusal  aspect  of 
the  case,  with  outline  of  fillings  and  point  of  contact.  Fig.  67 
shows  a  section  mesio-distally  at  the  contact  point. 

In  view  of  the  importance  of  making  contact  points  of  the 
proper  form  and  size  on  all  proximal  fillings,  it  would  seem  neces- 
sary to  study  somewhat  carefully  the  precise  form  and  the  exact 
area  of  contacts  found  in  normally  shaped  sound  teeth.  To  make 
an  ocular  examination  of  the  teeth  in  the  mouth  is  somewhat  mis- 
leading. With  the  teeth  standing  in  line  in  the  arch  and  the 
gums  filling  the  interproximal  spaces,  the  appearance  would  tend 
i,o  convey  the  impression  that  a  much  larger  area  of  enamel  was 
in  contact  than  is  actually  the  case.     The  presence  of  foreign  ma- 


102  PRINCIPLES    AND    PRACTICE    OF   FILLING    TEETH 

terial  or  even  of  moisture  clinging  to  the  proximal  surfaces  ob- 
scures the  vision  so  that  a  true  estimate  can  never  be  made  by  this 
kind  of  examination.  Neither  will  an  operator  be  likely  to  gain  a 
clear  conception  of  the  area  of  contact  by  an  examination  of  the 
teeth  singly  out  of  the  mouth  unless  in  cases  of  worn  facets,  which 
should  not  be  considered  as  typical  or  normal  contacts.  The 
variation  in  the  breadth  of  the  proximal  surfaces  of  the  different 
teeth  would  seem  to  imply  that  there  must  be  a  like  variation 
in  the  area  of  contact,  but  this  is  by  no  means  the  case. 

The  fact  is  that  the  area  of  enamel  in  actual  contact  even 
between  the  broadest  molars  is  normally  almost  infinitesimal,  and 
the  surest  means  of  determining  this  beyond  any  possibility  of 
doubt  is  to  take  two  such  teeth  that  have  been  extracted,  and, 
placing  them  together  in  the  same  relation  to  each  other  which 
they  sustained  in  the  mouth,  hold  them  up  to  the  light  with  the 
buccal  surfaces  presented  to  the  operator.  It  will  be  seen  at 
what  a  minute  point  the  light  is  obscured  by  contact — a  point  so 
very  small  as  scarcely  to  admit  of  measurement.  Now  turn  the 
teeth  so  that  the  occlusal  surfaces  are  presented  to  the  operator 
and  a  similar  result  is  apparent,  or  if  possible  intensified.  This 
is  an  object  lesson  in  the  area  of  contact  between  teeth  at  once  so 
apparent  and  so  vivid  that  the  experiment  should  not  be  ignored 
by  any  dentist  who  is  called  upon  to  fill  cavities  in  these  surfaces. 

This  must  not  imply  that  all  proximal  surfaces  have  the  same 
form,  or  that  the  contact  points  are  located  in  the  same  place  on  all 
teeth.  A  close  study  of  the  anatomical  features  of  the  proximal 
surfaces  of  the  different  teeth  will  reveal  a  great  variation  in  form, 
and  this  variation  should  be  respected  in  the  building  of  fillings. 
For  instance,  a  lower  second  bicuspid  usually  presents  a  proximal 
surface  somewhat  rounded  bucco-lingually  at  the  contact  point, 
and  sloping  away  from  this  point  buccally  and  lingually  with  a 
relatively  equal  degree  of  curvature.  This  brings  the  contact 
point  nearly  midway  between  the  buccal  and  lingual  surfaces,  and 
calls  for  a  generally  rounded  form  to  the  filling.  On  the  contrary, 
the  upper  first  molar  presents  on  its  mesial  aspect  a  greatly  flat- 
tened surface  with  the  contact  point  located  much  nearer  the 
buccal  than  the  lingual  surface,  and  sloping  away  abruptly  toward 
the  buccal  and  gradually  toward  the  lingual.  Speaking  in  a  gen- 
eral way,  it  will  be  found  that  in  making  the  contact  point  on 
fillings  the  distinction  should  be  made  between  the  upper  bicuspids 
and  molars  and  the  lower  ones,  that  on  the  former  it  should  be 


CLASSIFICATION    AND    PEEPARATION    OF    CAVITIES  103 

located  much  nearer  the  buccal  than  the  lingual  surface,  while 
on  the  latter  it  should  be  more  nearly  midway  between  the  two. 
The  location  of  the  contact  point  occluso-gingivally  is  quite  uni- 
form in  both  jaws,  the  common  rule  being  to  find  it  near  the  oc- 
clusal surface  sloping  abruptly  with  a  sharp  curve  toward  this 
surface  and  falling  away  gradually  toward  the  gingival. 

There  is  often  a  marked  difference  between  the  prominence  of 
the  contact  point  on  the  mesial  and  on  the  distal  surfaces  which 
applies  to  both  the  upper  and  lower  teeth,  the  distal  surfaces 
usually  presenting  a  bolder  and  more  rounded  prominence  than  the 
mesial,  and  therefore  curving  sharply  to  the  gingival.  This  re- 
sults in  such  a  form  to  the  interproximal  spaces  that  they  incline 
with  their  apices  directed  somewhat  backward,  and  their  mesial 
boundary  a  trifle  larger  than  their  distal. 

To  gain  the  most  intelligent  idea  of  the  actual  form  of  the  in- 
terproximal spaces  and  the  variations  in  the  proximal  surfaces 
of  the  teeth,  a  close  study  should  be  made  of  a  well-formed  jaw 
from  a  skeleton  with  the  teeth  in  their  normal  position  in  the 
arch.  An  examination  of  such  a  jaw  from  the  buccal,  the  lingual, 
and  the  occlusal  aspects  will  place  the  operator  in  a  more  enlight- 
ened relation  to  the  subject  than  can  be  attained  in  any  other 
way. 

In  judging  the  area  of  contact  between  teeth  in  the  mouth  or 
between  fillings,  the  most  convenient  test  is  the  ligature.  If  a 
ligature  be  passed  between  the  proximal  surfaces  of  teeth  having 
normal  contact  points  it  will  bind  quite  tightly  near  the  occlusal 
surfaces  as  if  meeting  a  sudden  obstruction,  but  this  obstruction 
is  narrow  and  the  ligature  readily  springs  past  it  under  pressure, 
and  moves  back  and  forth  with  the  greatest  freedom  in  the  inter- 
proximal space.  In  lifting  the  ligature  out  of  the  space  it  should 
pass  nearly  to  the  occlusal  surface  before  being  engaged  by  the 
contact  points,  and  should  then  come  out  from  between  the  teeth 
with  a  sudden  snap.  If  the  ligature  drags  in  passing  the  contact 
points,  or  if  it  is  frayed  against  the  surfaces,  the  contact  is  not 
normal  whether  it  be  on  a  filling  or  on  a  tooth. 

This  matter  of  the  lodgment  of  food  between  teeth  is  not 
studied  with  suflftcient  care  by  the  profession  generally.  As  has 
been  intimated  it  is  one  of  the  greatest  evils,  next  to  caries,  that 
confronts  the  profession.  It  is  not  only  a  question  of  the  dis- 
comfort of  the  patient  but  it  introduces  an  element  of  gravest 
danger  to  the  welfare  of  the  entire  mouth.     If  allowed  to  exist 


104  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

for  any  time  it  will  invariably  result  not  only  in  decay  of  the 
proximal  surfaces  of  the  teeth,  but  in  pyorrhea  pockets  which 
will  soon  cause  absorption  of  the  supporting  structures  of  the 
teeth  with  consequent  loosening  and  loss  of  these  organs. 

Occasionally  we  may  find  food  lodging  between  sound  teeth 
and  even  teeth  where  the  contact  seems  to  be  good.  A  study 
of  the  cause  must  be  made  and  the  difficulty  remedied.  If  it  is 
due  to  broad  contacts,  such  as  flat  fillings  or  worn  facets  in  the 
enamel,  these  should  be  cared  for,  as  has  already  been  indicated. 
If  the  contact  is  good  then  the  trouble  is  invariably  caused  by  the 
form  or  character  of  the  cusp  of  the  occluding  tooth.  A  careful 
examination  will  usually  reveal  the  fact  that  the  cusp  has  grown 
up  between  the  affected  teeth  in  such  a  way  as  to  act  as  a  wedge 
and  spring  the  teeth  apart  at  each  closure  of  the  jaws.  Even 
where  this  is  not  apparent  to  the  eye  from  an  examination  along 
the  buccal  aspect  of  the  teeth  on  closure,  it  can  be  proved  to  be 
the  case  by  taking  an  impression  of  the  teeth  in  this  region  and 
pouring  models  so  that  an  examination  may  be  made  of  the  re- 
lation of  the  upper  teeth  to  the  lower  teeth  from  the  lingual 
aspect.  Have  the  patient  bite  into  some  modeling  compound, 
and  pour  models  in  plaster.  This  will  usually  reveal  a  condi- 
tion which  accounts  for  the  trouble.  The  remedy,  of  course,  is 
to  grind  away  quite  freely  the  offending  cusp,  which  will  ordina- 
rily in  a  very  short  time  bring  complete  relief. 

More  and  more  the  profession  must  rouse  itself  to  the  gravity 
of  this  question.  It  will  not  do  to  longer  permit  teeth  to  be  lost 
from  this  cause,  as  so  many  have  been  in  the  past.  It  is  an  affec- 
tion the  responsibility  of  which  must  ever  rest  with  the  practi- 
tioner rather  than  with  the  patient.  The  latter,  even  where  he 
suffers  discomfort,  cannot  be  expected  to  realize  the  danger  or  sug- 
gest aremedy.  In  many  instances  he  is  not  even  aware  that  any- 
thing unusual  is  happening  when  food  lodges  between  the  teeth. 
He  looks  upon  it  as  a  necessary  concomitant  of  the  process  of 
mastication  and  goes  on  day  after  day  and  month  after  month 
jabbing  blunt  wooden  toothpicks  between  his  teeth,  and  adding 
immeasurably  to  the  complication  by  punishing  the  gum  in  the 
interproximal  spaces  and  keeping  up  the  irritation.  The  dentist 
must  invariably  be  on  the  alert  in  examining  every  mouth  which 
comes  under  his  care  to  detect  evidence  of  injury  to  the  inter- 
proximal tissues,  and  should  not  cease  in  his  efforts  in  each  case 
till  he  has  remedied  the  condition,  and  instructed  the  patient 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES  105 

as  to  its  significance.  It  has  often  been  remarked  that  one  of  the 
most  important  functions  of  the  dentist  is  to  educate  the  patient 
in  regard  to  matters  concerning  the  teeth,  and  in  no  department 
of  our  work  is  this  more  emphatically  true  than  in  the  one  under 
consideration. 

Separating  the  Teeth 

In  those  cases  where  the  decay  has  not  progressed  very  far 
and  where  there  has  been  little  breaking  down  of  the  contact 
point  and  consequently  no  dropping  together  of  the  teeth,  suf- 
ficient space  may  often  be  obtained  by  the  separator,  the  proper 
use  of  which  has  already  been  indicated.  But  where  any  con- 
siderable movement  of  the  teeth  is  necessary  it  is  more  safely 
and  comfortably  accomplished  by  gradual  wedging.  The  same 
system  may  be  employed  as  was  advocated  for  anterior  teeth, 
with  the  exception  that  a  more  extended  use  may  be  made  of 
gutta-percha.  This  substance,  if  properly  employed,  is  really  the 
ideal  material  for  separating  bicuspids  and  molars,  and  its  more 
general  use  would  do  much  to  remove  the  prejudice  existing 
against  having  teeth  wedged. 

It  may  be  used  in  the  following  manner:  The  occlusal  wall 
should  be  broken  down  in  those  cases  where  it  is  still  standing, 
and  the  cavity  cleared  of  debris  and  softened  dentin  with  a  few 
sweeps  of  a  broad  spoon  excavator.  It  should  then  be  flooded 
with  an  essential  oil  and  the  excess  wiped  out,  leaving  the  cavity- 
walls  soaked  in  the  oil.  Gutta-percha  should  then  be  packed 
into  the  cavity  and  snugly  against  the  proximating  tooth,  so  that 
pressure  may  be  exerted  between  this  tooth  and  the  axial  wall  of 
the  cavity.  The  gutta-percha  should  be  built  up  sufficiently  for 
the  cusp  of  the  opposing  tooth  to  impinge  upon  it  in  closing  the 
jaws,  and  the  repeated  impact  thus  resulting  will  tend  to  spread 
the  gutta-percha  and  force  the  teeth  apart.  By  this  method  teeth 
may  be  separated  with  very  little  soreness,  it  being  the  rarest  ex- 
ception for  a  patient  ever  to  complain  of  this  sort  of  wedge.  The 
process  is  somewhat  slow,  but  it  may  be  hastened  in  emergency 
cases  by  first  applying  the  separator  and  lifting  the  teeth  as  far 
apart  as  practicable  before  packing  the  gutta-percha.  Ordina- 
rily without  the  use  of  the  separator  the  gutta-percha  may  be  left 
in  for  a  week,  and  if  at  the  end  of  that  time  there  is  not  sufficient 
space,  fresh  gutta-percha  may  be  added  and  the  case  dismissed 
for  another  week. 


106  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

To  economize  time  in  the  management  of  these  cases,  it  is  well 
for  the  operator,  on  examining  a  mouth  where  several  fillings  are 
needed,  to  select  these  proximal  cases  at  the  first  sitting  and 
pack  gutta-percha  in  each  of  them.  He  may  then  proceed  with 
the  other  necessary  work  in  the  mouth,  and  by  the  time  that  is 
completed  some  of  the  teeth  thus  wedged  will  be  found  ready  to 
operate  upon.  The  more  stubborn  cases  may  be  left  till  the  last, 
and,  if  necessary,  the  gutta-percha  may  be  renewed  in  these  as 
the  other  operations  are  under  progress. 

Where  the  cavity  slopes  so  rapidly  from  the  axial  wall  to  the 
gingival  margin  as  to  result  in  a  sliding  of  the  gutta-percha  into 
the  interproximal  space  instead  of  exerting  lateral  pressure,  the 
gingival  wall  should  be  somewhat  flattened  previous  to  inserting 
the  wedge.  The  gutta-percha  will  then  rest  on  a  broad  base  and 
will  spread  under  pressure,  exerting  force  in  the  required  direction. 

When  gutta-percha  is  used  in  this  way,  or  when  it  is  employed 
for  sealing  medicaments  in  proximal  cavities  or  for  any  temporary 
purpose,  it  should  be  so  built  out  buccally  and  lingually  as  to 
impinge  on  the  buccal  and  lingual  festoons  of  gum  to  force  them 
back  on  a  level  with  the  giim  midway  between  the  teeth.  There 
are  two  reasons  for  doing  this.  It  keeps  the  festoons  out  of  the 
way  during  the  operation,  thus  preventing  their  laceration  by 
files  or  finishing  strips  and  affording  better  access  to  the  work, 
and  it  also  leaves  the  gum  in  the  best  possible  condition  for  re- 
occupying  the  interproximal  space  after  the  operation.  If  the 
festoons  are  left  further  crownwise  than  the  gum  between  the 
teeth,  it  results  in  an  inverted  arch  or  pocket  into  which  food  may 
pack,  thus  retarding  the  healthy  growth  of  the  gum.  If  the 
festoons  are  pressed  back  so  that  they  are  not  lacerated  and  a 
favorable  form  is  left  to  the  gum  after  operating,  it  will  be  found 
that  the  gum  will  quickly  creep  back  into  the  space  and  occupy  it 
in  a  healthy  condition. 

Details  of  Cavity  Formation 

In  those  cases  where  the  occlusal  wall  is  still  standing  and  it 
becomes  necessary  for  the  operator  to  break  it  down,  it  is  a  matter 
of  some  importance  to  know  how  to  do  it  to  the  best  advantage. 
The  arch  of  enamel  overhanging  the  cavity  at  this  point  is  often 
strongly  resistant,  and  if  the  attempt  is  made  to  crush  it  in  with  a 
chisel,  as  is  frequently  done  by  operators,  the  result  is  ordinarily 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES  107 

a  somewhat  severe  shock  to  the  patient.  This  shock,  coming  in 
the  early  stages  of  the  operation,  has  a  tendency  to  unnerve  the 
patient  and  create  an  apprehension  which  often  lasts  through  the 
entire  sitting.  As  has  already  been  intimated,  all  unnecessary 
violence  must  be  avoided,  particularly  when  the  patient  first 
takes  the  chair. 

To  open  these  cavities  comfortably,  a  slot  should  be  drilled 
through  the  arch  as  illustrated  in  Fig.  68,  which  practically  re- 
moves the  keystone  of  the  arch  and  destroys  its  main  support. 
If  a  small  sharp  drill  be  used,  with  the  engine  revolving  rapidly, 
this  slot  may  be  made  without  appreciable  discomfort,  and  the  en- 
amel may  then  be  broken  down  with  a  chisel,  as  shown  in  Fig.  69. 


Fig.  68.  Fig.  69.  •  Fig.  70. 

The  chisel  should  be  held  at  the  angle  indicated  and  pressed  firmly 
against  the  enamel  to  prevent  gliding.  If  the  proper  angle 
be  maintained,  it  will  require  only  the  slightest  tap  of  the  mallet 
to  break  the  enamel  away.  Chisels  for  cleaving  enamel  should 
be  made  keenly  sharp,  so  that  they  "bite"  into  the  surface  imme- 
diately at  the  point  where  they  are  held,  instead  of  sliding  along 
the  surface  with  a  grating,  rasping  sensation  so  distressing  to 
most  patients. 

After  the  cavity  has  been  thoroughly  opened,  the  walls  may  be 
formed  as  follows: 

The  Gingival  Wall. — The  margin  of  this  wall  should  be  extended 
far  enough  rootwise  to  carry  it  well  under  the  gum  in  accord- 
ance with  the  outline  in  Fig.  58.  The  degree  of  extension  will 
differ  in  different  cases.  In  those  teeth  where  there  has  been  little 
decay  and  where  the  gum  fills  the  interproximal  spaces  normally 
to  the  contact  points,  it  will  not  require  much  extension  to  bring 
the  margin  safely  under  the  gum;  but  in  mouths  where  the  gums 
have  receded  in  the  spaces  and  where  the  tendency  to  proximal 
decay  is  great,  it  will  call  for  more  extensive  cutting  to  insure  the 
most  permanent  operation. 

In  other  cases  where  there  has  been  great  recession  of  the  gums, 
but  where  the  gum-tissue  is  firm  and  otherwise  normal,  and  where 


108  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

the  cavity  has  occurred  near  the  contact  point,  with  a  con- 
siderable area  of  sound  enamel  between  the  gingival  margin  of  the 
cavity  and  the  gum,  it  would  be  too  radical  to  cut  through  this 
sound  enamel  to  bring  the  margin  under  the  gum,  nor  do  such 
cases  call  for  it.  They  ordinarily  belong  to  aduLt  life  where  the 
susceptibility  to  recurrence  of  decay  is  lessened. 

The  form  of  the  wall  bucco-lingually  should  be  flat,  and  it 
should  be  made  wide  enough  in  this  direction  to  furnish  a  broad 
base  for  the  filling  to  rest  upon  and  to  bring  the  gingivo-buccal 
and  gingivo-lingual  angles  to  a  point  of  safety  against  recurrence 
of  decay.  The  wall  should  also  be  flat  mesio-distally,  and  it  should 
join  the  axial  wall  at  right  angles.  In  some  instances,  where 
great  security  of  the  filling  is  required,  or  where  it  may  seem 
difficult  to  start  the  filling,  the  wall  may  be  made  to  dip  slightly 
rootwise  as  it  approaches  the  axial  wall,  but  a  groove  should  not 
be  drilled  along  the  gingival  wall,  as  is  often  advocated.  To 
groove  this  wall  results  in  the  formation  of  a  ridge  of  tissue  along 
the  margin  of  the  cavity,  against  which  it  is  difficult  to  adapt 
gold  without  injuring  the  enamel. 

As  the  gingival  wall  joins  the  buccal  or  lingual  wall  it  should 
form  a  distinct  angle  in  the  axial  region,  but  should  execute  a 
short  curve  at  the  enamel-margin.  The  angle  thus  formed  in  the 
gingivo-linguo-axial  corner  of  the  cavity  forms  an  excellent  means 
for  securing  the  first  pieces  of  gold  in  position,  and  the  general 
form  of  the  gingival  wall  when  shaped  as  just  outlined  affords  a 
base  upon  which  the  filling  may  be  built  without  danger  of  the 
gold  rocking  under  the  plugger-point.  A  rounded  gingival 
wall,  or  in  other  words  a  curved  base,  is  responsible  for  much  of 
the  difficulty  experienced  by  some  operators  in  starting  these 
.fillings. 

The  width  of  the  wall  mesio-distally  must  be  governed  by  the 
extent  of  tooth-tissue  available.  The  cavity  should  have  ag 
wide  a  base  as  possible  without  endangering  the  pulp.  In 
this  connection  the  location  of  the  pulp-chamber  in  the  various 
teeth  should  be  carefully  studied  by  the  operator,  so  that  he 
may  judge  intelligently  how  far  he  can  extend  his  cavities  with 
safety.  Fig.  70  illustrates  a  section  of  a  bicuspid  mesio-distally 
with  the  form  of  the  gingival  wall. 

The  Buccal  and  Lingual  Walls. — As  already  intimated,  the  form 
usually  given  these  walls  by  operators  is  to  groove  them  with  the 
idea  of  anchoring  the  filling — the  limitations  of  which  method 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES 


109 


have  already  been  pointed  out.  There  are  some  cases,  it  is  true, 
where  these  walls  must  be  made  to  sustain  the  filling;  such,  for 
instance,  as  lower  first  bicuspids  with  an  exceedingly  long  buccal 
cusp  and  a  diminutive  lingual  cusp  joined  by  a  perfect  fusion  of 
enamel.  In  these  cases  we  have  no  opportunity  for  creating  a 
step  on  the  occlusal  surface,  and  really  little  necessity  for  doing 
so,  owing  to  the  conical  shape  of  the  teeth  and  the  consequent 
limited  tipping  stress  on  the  filling.  The  occlusal  surface  of  a 
proximal  filling  in  one  of  these  teeth  presents  a  sloping  surface  to 
the  cusp  of  the  upper  tooth,  and  there  is  practically  no  lever- 
age to  dislodge  it.  A  slight  buccal  and  hngual  retention  in  the 
form  of  shallow  grooves  in  connection  with  a  broad,  flat  seat  or 
gingival  wall  is  all  that  is  required  to  retain  the  filling. 


Fig.  71. 


Fig.  72. 


Fig.  7.3. 


Fig.  74. 


But  for  ordinary  cases  grooving  along  these  walls  should  be 
avoided,  though  a  possible  retentive  shape  should  not  be  ignored 
in  their  formation.  This  may  be  secured  by  making  an  angle 
between  these  walls  and  the  axial  wall  in  such  a  way  that  the 
cavity  is  slightly  wider  bucco-lingually  at  the  axial  wall  than  it  is 
at  the  dento-enamel-margin  (Fig.  71).  This  may  be  done 
without  materially  weakening  the  walls,  and  the  mortise  or  dove- 
tail form  thus  provided  is  an  element  of  security  to  the  filhng. 
This  mortised  effect  should  be  carried  from  the  gingival  wall 
throughout  the  length  of  the  buccal  and  lingual  walls  till  they 
approach  the  enamel  on  the  occlusal  surface,  where  they  should 
merge  into  the  form  shown  in  Fig.  59c.  This  kind  of  wall  pre- 
sents a  surface  against  which  gold  may  readily  be  adapted,  and 
the  filling-material  once  locked  between  these  two  perpendicular 
walls  is  securely  held  in  place.  The  building  of  fillings  in  cavities 
thus  formed  is  a  very  simple  matter. 

The  Step. — This  should  be  cut  at  right  angles  with  the  proxi- 
mal portion  of  the  cavity,  and  should  present  a  flat  base  for  the 
filling-material  to  rest  upon.     Its  width  bucco-lingually  and  its 


110  PRINCIPLES   AND    PRACTICE    OF   FILLING   TEETH 

depth  pulpally  should  be  governed  by  the  form  of  the  tooth.  If 
it  is  a  short,  thick  tooth,  the  step  should  be  made  correspondingly 
wide,  with  a  diminished  depth,  while  if  the  tooth  be  long  and  thin 
the  step  may  be  narrowed  and  deepened.  The  object  in  any  case 
is  to  secure  a  sufficient  bulk  of  filling-material  in  the  step  to  afford 
strength — which  is  particularly  true  at  the  point  where  the  step 
joins  the  proximal  portion  of  the  cavity.  The  step  should  be 
made  as  wide  and  deep  here  as  is  practicable  without  undermining 
the  cusps  or  weakening  the  tooth  between  the  cusps  so  as  to 
render  it  hable  to  split.  Particular  study,  especially  in  bicuspids, 
should  be  given  to  this  question  of  spUtting  in  its  relation  to  the 
depth  of  the  step  pulpally.  A  safe  rule  to  follow  is  to  drill  as 
deeply  between  the  cusps  as  the  fissure  extends  pulpally,  and 
make  the  base  of  the  step  at  this  point.  This  cannot  result  in  any 
greater  tendency  to  fracture  than  existed  before,  because  of  the 
fact  that  wherever  there  is  a  fissure  there  is  no  binding. strength 
represented  throughout  its  extent. 

The  buccal  and  lingual  walls  of  the  step  should  be  made  per- 
pendicular, with  an  angle  between  them  and  the  pulpal  wall  (Fig. 
72) .  The  end  of  the  step  most  remote  from  the  proximal  portion 
of  the  cavity  should  also  have  a  perpendicular  form,  and  the  step 
at  this  point  may  often  be  widened  bucco-lingually  in  those  teeth 
having  a  notable  depression  on  the  occlusal  surface  at  the  termina- 
tion of  the  fissure.  This  results  in  a  dovetail  form,  which  aids  in 
the  retention  of  the  fiUing. 

The  Axial  Wall. — The  shape  of  this  wall  will  be  governed  mate- 
rially by  the  depth  of  the  decay.  Where  there  is  little  penetra- 
tion of  the  carious  process  it  should  be  made  perpendicular  and  at 
right  angles  with  the  gingival  wall.  In  cases  of  deep  decay  with 
a  concave  axial  wall  it  may  be  well  to  create  a  new  axial  wall  with 
cement,  which  will  afford  protection  to  the  pulp  and  give  a  better 
form  to  the  filling.  The  cement  should  not  be  built  out  so  far 
as  to  result  in  leaving  the  metal  filling  too  thin  for  strength. 
Veneer  filHngs  of  this  character  cannot  be  depended  on  for  ex- 
tended service.  The  axial  wall  should  never  be  left  sloping  from 
the  step  to  a  narrow  gingival  wall,  on  account  of  the  tendency  of 
the  filhng  to  shift  under  stress  when  built  against  an  inclined 
surface  such  as  this  would  present. 

The  Enamel-Margins.— Th&  buccal  and  lingual  margins  should 
be  beveled  to  a  greater  extent  than  in  any  other  part  of  the  outline 
of  the  cavity.     The  gingival  margin  need  be  beveled  but  very 


CLASSIFICATION   AND    PREPARATION    OF    CAVITIES  HI 

little  on  account  of  the  lack  of  lateral  violence  against  such  a  sur- 
face, and  also  because  of  the  difficulty  of  producing,  a  perfect 
bevel  in  this  region  and  building  the  filling  over  it.  This  does 
not  hold  true  of  cavities  prepared  for  inlays,  as  will  be  mentioned 
later.  On  the  occlusal  surface  the  slope  of  the  enamel  down  to 
the  cavity-margin  and  the  proper  shaping  of  the  walls  result  in  a 
margin  which  requires  very  little  beveling  by  the  operator. 
Care  must  of  course  be  exercised  that  in  forming  the  margins  no 
overhanging  enamel  be  left.  If  the  slightest  ledge  of  unsupported 
enamel  is  allowed  to  remain,  it  will  quickly  be  fractured  by  the 
stress  of  mastication. 

Technique. — In  opening  the  cavity  aU  friable  or  overhanging 
enamel  should  be  broken  down  by  chisels,  and  in  this  connection 
some  study  should  be  made  of  the  proper  angle  at  which  a  chisel 
must  be  held  in  order  to  cleave  enamel  to  the  best  advantage. 
Enamel  will  bear  appreciable  pressure  without  fracture  if  the  force 
is  exerted  upon  it  in  certain  directions,  but  a  shght  deviation  of 
the  force  may  be  made  to  result  in  a  ready  parting  of  the  enamel- 
prisms.  Advantage  should  be  taken  of  this  characteristic  of 
enamel  so  that  overhanging  walls  may  be  broken  down  with  the 
least  possible  force.  Little  can  be  definitely  taught  as  to  the 
precise  angle  at  which  the  chisel  should  be  held  for  the  best  results 
in  varying  cases,  but  the  observant  operator  wiU  readily  learn  to 
detect  the  vulnerable  points  in  overhanging  enamel  and  know  best 
how  to  attack  it. 

The  character  of  the  force  exerted  on  the  chisel  also  becomes  im- 
portant. Wherever  an  angle  of  enamel  is  to  be  broken  down  or 
where  there  is  any  appreciable  bulk  of  tissue  to  be  cleaved  away, 
it  is  best  and  most  comfortably  accomplished  by  a  sharp,  decisive 
blow  of  the  mallet  on  the  chisel.  But  where  it  is  merely  a  question 
of  cavity  extension  or  a  trimming  of  ragged  or  frail  walls,  hand 
pressure  on  the  chisel  is  preferable.  When  used  in  this  way  care 
should  be  exercised  not  to  allow  the  chisel  to  slip  into  the  cavity 
and  impinge  on  sensitive  tissue.  The  hand  should  be  guarded 
and  kept  under  perfect  control  by  bracing  the  ends  of  the  fiingers — 
the  ones  not  used  in  holding  the  chisel — firmly  against  the  teeth. 
This  work  may  in  certain  positions  be  best  accomplished  by  grasp- 
ing the  chisel  in  the  palm  of  the  hand  and  allowing  the  end  of  the 
thumb  to  rest  against  the  teeth  as  a  brace. 

The  next  step  is  to  give  form  to  the  cavity-walls.  An  inverted 
cone  bur  of  suflacient  size  to  cover  the  gingival  wall  mesio-distally 


112  PKINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

should  be  placed  with  its  end  on  this  wall,  as  illustrated  in  Fig.  73, 
and  carried  buccally  and  lingually  along  the  wall  till  the  proper 
extension  is  reached.  This  will  give  a  flat  form  to  the  gingival 
wall  and  create  an  angle  between  it  and  the  axial  wall.  Care 
should  be  exercised  that  the  blades  of  the  bur  do  not  penetrate  too 
close  to  the  pulp.  The  buccal  and  lingual  walls  may  often  be 
extended  with  the  same  bur  by  carrying  it  up  and  down  along 
these  walls — cutting  with  the  side  of  the  bur.  In  lower  teeth, 
or  in  distal  cavities  difficult  of  access  in  upper  teeth,  an  inverted 
cone  bur  in  the  contra-  or  right-angle  hand-piece  will  be  most 
effective.  After  the  walls  have  been  extended  with  the  large 
bur  it  will  be  found  that  the  angles  between  the  buccal  and 
axial  or  lingual  and  axial  walls,  and  particularly  in  the  gingivo- 
bucco-axial  and  gingivo-linguo-axial  corners,  are  not  sufficiently 
well  defined.  A  smaller  inverted  cone  bur  used  in  the  same 
way  may  be  carried  into  these  angles  to  deepen  them,  and  if  a 
still  sharper  angle  be  required  it  can  be  made  with  hatchet  or  hoe 
excavators. 

As  the  small  inverted  cone  bur  is  being  used  along  the  gingival 
wall  it  should  be  carried  laterally  somewhat  into  the  buccal  and 
lingual  walls  at  this  point  and  then  withdrawn  a  short  distance 
crownwise  along  the  gingival  third  of  these  walls.  This  will 
result  in  an  angle  or  pocket  into  which  the  first  pieces  of  gold 
may  readily  be  secured.  Such  a  form  as  this  is  especially  service- 
able for  beginners,  who  may  otherwise  find  difficulty  in  starting 
these  fillings.  If  there  is  much  softened  dentin  along  the  axial 
wall  it  may  be  removed  with  spoon  excavators. 

In  forming  the  step,  the  fissure  in  the  occlusal  surface  may  be 
opened  up  with  a  small  drill,  a  suitable  form  for  this  purpose  being 
readily  made  from  a  worn-out  inverted  cone  bur  by  grinding  it  on 
two  sides  to  a  sharp  edge,  as  illustrated  in  Fig.  74.  This  form  of 
drill,  small  in  size  and  ground  sharp,  may  be  made  to  walk 
directly  through  between  the  two  plates  of  enamel  bordering  a 
fissure  by  revolving  the  engine  rapidly  and  swaying  the  hand- 
piece back  and  forth,  so  that  the  sharp  corners  of  the  drill  effect- 
ively bite  into  the  enamel.  When  a  narrow  trench  is  thus  made 
it  may  be  widened  with  a  chisel,  after  which  the  floor  of  the  step 
may  be  formed  with  an  inverted  cone  bur  stood  with  its  end  on  the 
floor.  This  results  in  the  desired  flat  base  to  the  step,  while  the 
sides  of  the  bur  give  form  to  the  walls. 

The  gingival  enamel-margin  may  be  given  the  slight  degree  of 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES  113 

bevel  necessary  with  suitably  formed  chisels  or  long-shanked  ex- 
cavators. Sometimes  in  cases  of  good  access  a  round  bur  with 
shallow  blades  may  be  passed  along  this  margin  to  advantage,  or 
what  is  better  a  fine  stone  in  the  engine.  For  beveling  the  buccal 
and  lingual  enamel  a  thin,  sharp  chisel  may  be  used  to  plane  down 
the  peripheral  margin,  but  what  is  far  preferable  in  those  cases 
where  it  can  be  used  is  a  sand-paper  disk  in  the  engine.  This,  if 
held  at  a  definite  angle,  will  give  the  required  bevel,  and  will  leave 
a  margin  clearly  cut,  and  symmetrical.  Care  must  of  course  be 
exercised  not  to  round  the  margin  with  the  disk  by  swaying  the 
hand-piece  as  the  disk  is  revolving,  nor  must  too  fine  a  disk  be 
used  through  danger  of  polishing  the  enamel-margin  smooth. 
If  the  enamel  is  polished  it  will  be  found  more  difficult  to  properly 
seal  the  cavity  against  leakage  with  gold  foil. 

General  Considerations 

While  the  form  of  cavity  here  recommended  is  believed  to  be 
the  best  adapted  for  the  majority  of  cases  applying  to  the  dentist, 
it  is  acknowledged  that  there  are  many  instances  where  it  cannot 
well  be  followed  out  in  all  of  its  details.  The  extent  of  the  decay 
is  sometimes  so  great  as  to  determine  the  shape  of  the  cavity- 
walls,  and  where  there  has  been  much  undermining  of  the  tissue 
the  operator  is  left  to  make  the  most  of  the  opportunities  pre- 
sented; but  the  principles  involved  in  cavity  formation  should 
never  be  lost  to  view,  and  every  cavity  should  be  made  to  con- 
form to  them  as  accurately  as  the  case  will  permit. 

A  distinction  is  sometimes  made  in  these  cavities  between  those 
intended  for  gold  and  those  for  amalgam.  So  far  as  the  general 
form  of  the  cavity  is  concerned,  there  should  be  no  distinction, 
except  that  for  amalgam  more  extensive  anchorage  is  usually 
required  than  for  gold.  Gold  if  properly  condensed  is  so  stable 
and  uniform  in  its  behavior  that  it  may  be  depended  on  to  remain 
placed  in  a  cavity  where  amalgam  with  its  freaks  and  fancies  will 
too  often  prove  insecure.  With  most  of  the  amalgams  in  use  it 
requires  a  much  greater  bulk  of  the  material  to  stand  a  given 
stress  than  it  does  of  gold,  and  the  anchorages  must  therefore  be 
broader  and  deeper,  and  the  bevel  of  enamel  along  the  margins 
not  quite  so  great.  With  these  exceptions  the  plan  of  cavity 
formation  should  be  the  same.  The  detail  of  cavity  preparation 
for  inlays  will  be  considered  later. 


114  PRINCIPLES    AND    PRACTICE    OF   FILLING    TEETH 

One  feature  relative  to  the  security  of  these  fillings  in  bicuspids 
and  molars  should  not  be  overlooked  in  estimating  the  extent  of 
anchorage  required.  It  is  too  often  the  case  that  operators  insert 
these  fillings  without  an  adequate  study  of  the  kind  of  service  they 
are  destined  to  perform.  Even  if  they  stop  to  consider  the  force 
of  mastication  in  its  relation  to  the  extent  of  anchorage,  it  is 
usually  only  with  the  idea  of  a  given  number  of  pounds  pressure 
which  may  be  exerted  on  the  fillings,  and  the  probability  of  a 
certain  area  of  anchorage  withstanding  such  a  pressure.  They  do 
not  consider  in  its  full  significance  the  feature  of  aggregate 
service.  It  is  the  constant  dripping  of  water  which  wears  away 
the  stone,  and  in  anchoring  these  fillings  we  must  provide  against 
a  series  of  masticating  impacts  so  numerous  in  extent  as  to  stagger 
one  who  has  not  studied  the  matter.  Persons  vary  greatly  in  the 
number  of  occlusions  they  make  during  a  meal,  as  they  do  in  the 
degree  of  force  used  in  masticating,  but  a  somewhat  close  observa- 
tion would  lead  to  the  belief  that  for  the  proper  mastication  of  an 
average  dinner  the  individual  will  make  at  least  one  thousand 
distinct  occlusions,  and  in  many  instances  it  will  greatly  exceed 
this.  Let  us  stop  to  consider  what  this  means  for  our  filling. 
Suppose  one-half  of  these  impacts  fall  on  one  side  and  that  one- 
half  of  these  come  against  the  filling.  This  is  really  a  low  esti- 
mate, because  many  persons  will  manage  a  bolus  of  food  on  each 
side  of  the  mouth  at  the  same  time,  and  this  bolus  will  extend . 
over  several  teeth.  At  a  moderate  computation  each  meal  will 
result  in  nearly  three  hundred  impacts  of  food  against  the  filling, 
varying  in  force  and  character  according  to  the  habit  of  the 
individual  and  the  nature  of  the  food.  When  it  is  remembered 
that  this  process  is  kept  up  three  times  a  day  for  three  hundred 
and  sixty-five  days  in  the  year,  it  will  soon  become  manifest  that 
our  fillings  must  be  anchored  against  some  pretty  severe  usage, 
and,  with  such  a  reckoning  as  this  constantly  before  him,  the 
conscientious  operator  will  proceed  to  his  work  with  the  greatest 
care  and  thoroughness,  to  the  end  that  it  may  be  made  as  per- 
manent as  possible. 

A  close  study  of  the  process  of  mastication  in  the  operator's 
own  mouth  in  its  relation  to  this  subject  is  strongly  recommended. 
The  nature  and  extent  of  the  force  used,  together  with  the  manner 
of  its  application  in  the  comminution  of  different  food  materials, 
are  fit  subjects  for  careful  observation;  and  an  intelligent  compre- 
hension of  the  forces  at  work  in  the  performance  of  mastication 


CLASSIFICATION    AND    PREPARATION    OP   CAVITIES  115 

will  place  the  operator  in  a  better  position  to  render  the  most 
perfect  service. 

Buccal,  Labial,  or  Lingual  Cavities 

All  cavities  occurring  in  either  of  the  three  surfaces — buccal, 
labial,  or  lingual — call  for  similar  treatment  so  far  as  the  prin- 
ciples of  cavity  formation  are  concerned,  except  the  small  rounded 
cavities  having  their  origin  in  the  pits  in  the  buccal  surfaces  of 
lower  molars  and  the  lingual  surfaces  of  the  upper  anterior  teeth. 
These  pitted  cavities  are  quite  distinct  in  character  and  environ- 
ment from  the  ordinary  buccal  and  lingual  decay  occurring  near 
the  gum-margin,  and  their  preparation  is  so  self-evident  as  not  to 
call  for  any  extended  or  detailed  description.  The  fact  that  they 
are  usually  the  result  of  structural  imperfections  in  the  tooth  at 
the  point  of  decay,  and  that  they  occur  in  surfaces  which  are  ordi- 
narily readily  cleansed  by  friction,  renders  it  necessary  only  to 
remove  the  carious  and  imperfect  tissue,  secure  good  margins,  and 
give  a  mortised  form  to  the  cavity.  No  extension  for  prevention 
is  required  in  these  cases. 

But  where  decay  occurs  near  the  gum-margin  and  extends  in  a 
crescent  form,  following  the  outline  of  the  gum  along  the  surface 
of  the  tooth,  the  problem  of  its  control  becomes  more  complicated. 
These  are  sometimes  accounted  the  most  difficult  of  all  cavities  to 
deal  with,  and  yet  if  properly  managed  they  will  respond  to  treat- 
ment with  most  gratifying  results. 

The  Cavity  Outline. — The  proper  marginal  outline  of  the  cavity 
becomes  a  matter  of  vital  importance  in  its  relation  to  the  prob- 
able permanence  of  the  operation.  The  reason  that  many  of 
these  fillings  fail  so  early  after  their  insertion  may  be  traced  to  the 
fact  that  in  the  preparation  of  the  cavity  the  margins  are  not 
extended  to  inclilde  all  of  the  affected  enamel.  If  we  study  the 
manner  of  progress  of  this  form  of  decay,  it  will  enlighten  us 
greatly  as  to  the  necessities  of  the  case  in  treatment.  Occasion- 
ally we  may  find  these  cavities  well  defined  in  outline  with  a 
notable  penetration  of  decay  at  a  given  point,  and  when  such  is 
the  case  with  a  surrounding  surface  of  perfect  enamel  our  method 
of  procedure  is  clear.  We  need  very  little  extension  of  the 
margins. 

But  in  the  vast  majority  of  cavities  occurring  in  these  surfaces 
it  will  be  found  that  the  area  of  decay  is  ill  defined,  and  that  the 
enamel  is  more  or  less  disintegrated  along  the  surface  leading  from 


Il6  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

the  cavity  and  following  the  In ar gin  of  the  gum.  This  affected 
enamel  must  invariably  be  included  in  the  cavity  outline  and 
replaced  by  filling-material  if  \ve  are  to  be  assured  of  permanent 
results.  The  fact  that  disintegration  has  commenced  is  con- 
clusive evidence  that  the  active  agent  of  caries  has  found  this 
particular  point  of  the  surface  suitable  field  upon  which  to  work 
its  destructive  processes,  and  the  assumption  is  clear  that  unless 
the  conditions  are  radically  changed  the  process  will  continue. 
The  surest  method  of  changing  the  conditions  is  to  remove  the 
area  of  tissue  upon  which  the  micro-organisms  of  caries  are  known 
to  act,  and  replace  it  with  filling-material  upon  which  they  cannot 
act.  This  one  fact  that  enamel  is  vulnerable  to  the  attack  of 
micro-organisms,  while  filling-material  is  not,  should  give  i^s  a 
clearer  conception  of  the  required  line  of  treatment  in  all  those 
positions  which  are  subject  to  the  influence  of  the  destructive 
agent. 

The  surface  of  the  enamel  surrounding  one  of  these  cavities 
ihust  be  critically  examined  for  defects.  Sometimes  a  crescentie 
line  of  discoloration  extends  from  the  cavity  in  such  a  manner  as 
to  confuse  the  operator  with  regard  to  the  true  condition  of  the 
enamel  under  it.  It  may  be  simply  a  discoloration  on  the  surface, ' 
with  sound  enamel  below  it,  or  the  enamel  may  be  softened  to  con- 
siderable depth  and  the  discoloration  tend  to  hide  the  defect. 
The  only  way  to  determine  the  true  condition  of  the  enamel  is  tO 
thoroughly  polish  away  the  discoloration  with  silex  carried  on  a 
brush  in  the  engine.  If  the  brush  succeeds  in  removing  all  the 
discoloration,  leaving  a  white  and  glistening  surface  to  the  enamel, 
we  may  know  that  the  destructive  agent  of  caries  has  not  yet 
affected  it;  but  if  the  enamel  shows  disintegration  on  its  surface 
after  the  brush  has  been  used,  we  must  cut  out  this  disintegrated 
tissue,  even  if  it  has  not  already  penetrated  the  entire  depth  of 
the  enamel. 

The  proper  extension  of  the  cavity  rootwise  involves  the  carry- 
ing of  this  margin  well  under  the  gum.  There  are  two  reasons  for 
this — first,  the  one  already  given  in  connection  with  proximal 
cavities,  that  wherever  the  filling  is  carried  under  the  free  margin 
of  the  gum  there  will  be  no  recurrence  of  decay  at  that  point,  and 
second,  that  the  gum  is  more  likely  to  remain  healthy  when  over- 
lapping a  smooth  filling  than  when  overlapping  tooth-tissue, 
particularly  if  there  has  been  any  recession  of  the  gum.  This 
latter  statement  may  appear  illogical  at  first  thought,  but  a  some- 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES  117 

what  close  clinical  observation  would  seem  to  confirm  it  beyond 
any  doubt,  and  a  careful  study  of  the  conditions  will  suggest  a 
tenable  reason  therefor.  In  all  cases  where  there  has  been  any 
extended  decay  it  will  be  found  that  the  margin  of  the  gum  has 
been  interfered  with  in  one  of  two  ways.  Either  the  decay  has 
crept  up  under  the  gum,  leaving  the  free  margin  lying  in  the 
cavity  in  an  unhealthy  condition,  or  else  the  gum  has  progress- 
ively receded  and  is  lying  against  the  cementum  instead  of 
enamel.  In  the  latter  case  the  gingival  outline  of  the  cavity  is 
usually  ill  defined,  with  little  penetration  of  the  carious  process. 
Under  either  of  these  conditions  the  gum  will  be  found  abnormal. 
If  in  the  preparation  of  the  cavity  we  press  back  the  gum  gently 
but  to  considerable  extent  and  make  the  gingival  margin  of  the 
filling  sufficiently  rootwise,  we  shall  find  that  the  gum  will 
rapidly  cover  it  in  a  healthy  condition.  Not  only  this,  but  in 
many  cases  the  gum  will  creep  so  far  crownwise  as  to  cover  the 
neck  of  the  tooth  and  filling  far  in  excess  of  its  position  before 
the  operation.  It  apparently  takes  more  kindly  to  a  smooth 
filling  than  it  does  to  cementum  which  may  be  denuded,  or  to 
enamel  which  may  be  slightly  roughened.  Some  extreme  cases 
of  this  kind  of  gum-reproduction  have  been  noted,  particularly 
in  cuspids,  where  the  gum  has  been  known  to  cover  the  gingival 
portion  of  a  filling  to  the  extent  of  two  millimeters.  Such 
results  as  these  are  sufficiently  gratifying  to  reward  the  operator 
for  the  necessary  expenditure  of  energy,  and  the  patient  for  the 
discomfort  accompanying  the  work. 

In  Fig.  75  will  be  seen  a  central  incisor,  with  the  cavity  a  pene- 
trating through  the  enamel,  h  defective  enamel  extending  from 
cavity,  and  c  the  proper  outline  of  filling. 

The  Cavity-Walls. — The  plan  of  anchorage  for  these  fillings  is 
exceedingly  simple.  There  is  no  need  for  the  deep  undercutting 
sometimes  resorted  to  by  operators,  all  that  is  necessary  being  tO' 
give  a  mortised  form  to  the  cavity  by  making  the  axial  wall  flat 
and  the  surrounding  walls  at  right  angles  to  it.  At  two  points  in 
the  cavity  it  is  well  to  make  a  slight  dovetail  to  more  securely  lock 
the  filling  into  place,  viz.,  at  the  mesial  and  distal  extremities.  Jo 
this  end  the  axial  wall  should  be  made  slightly  wider  mesio- 
distally  than  the  orifice  of  the  cavity  at  the  dento-enamel- 
margin.  This  is  especially  true  where  amalgam  is  to  be  used  on 
the  buccal  or  lingual  surfaces  of  molars. ,  Amalgam  requires 
broader  and  deeper  anchorages  to  hold  it  in  place  than  does  gold, 


118  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

and  this  fact  should  be  noted  particularly  in  those  cases  on  molars 
where  the  cavity  passes  so  far  mesially  and  distally  as  to  curve 
somewhat  toward  the  proximal  surfaces.  These  are  the  cases 
where  amalgam  is  so  often  seen  to  curl  away  from  the  cavity  at 
the  extremities,  admitting  a  leak  around  the  filling.  If  amalgam 
is  to  be  held  securely  in  position  in  buccal  or  lingual  cavities,  it 
must  be  placed  in  broad,  dovetailed  anchorages.  The  preparation 
of  this  class  of  cavities  for  inlays  will  be  considered  later. 


Fig.  75.  Fig.  76.  Fig.  77.         Fig.  78. 

Technique. — In  many  of  these  cases  it  will  be  found  that  while 
the  enamel  is  completely  disintegrated  and  dissolved  away, 
the  dentin  maintains  practically  its  original  form,  being  simply 
softened  or  decalcified  for  considerable  depth  without  breaking 
down.  This  softened  mass  of  dentin  is  best  removed  with  a 
hatchet  excavator,  the  blade  of  which  is  thin,  delicate,  and  ex- 
ceedingly sharp.  The  keen  edge  of  the  blade  is  placed  on  end  at 
one  extremity  of  the  cavity  and  forced  to  the  full  depth  of  the 
decay.  Then  by  a  dextrous  turn  the  whole  carious  mass  is  rolled 
out  of  the  cavity  in  one  piece,  thus  removing  at  a  single  sweep  what 
is  ordinarily  the  most  sensitive  portion  of  the  tissue.  This,  if 
done  skillfully,  is  usually  not  a  very  painful  proceeding,  but  there 
must  be  no  half  measures  about  it.  Any  picking  or  manipulation 
of  the  carious  mass  bit  by  bit  is  simply  excruciating  as  well  as 
ineffective.  The  operator  should  be  at  the  same  time  gentle  and 
thorough.  His  touch  should  be  delicate  and  forceful,  his  move- 
ments definite  and  rapid. 

When  the  softened  dentin  is  removed  with  the  excavator  the 
next  step  is  to  give  form  to  the  walls.  This  is  best  done  with  an 
inverted  cone  bur  stood  with  its  end  against  the  axial  wall  (Fig. 
76),  and  carried  mesially  and  distally  across  the  cavity  till  the  de- 
sired form  is  obtained.  This  kind  of  bur  gives  the  proper  shape 
to  the  walls  and  leaves  a  mortised  effect,  as  shown  in  Fig.  77. 
As  the  bur  approaches  the  mesial  and  distal  walls  of  the  cavity  it 
should  be  carried  somewhat  into  these  walls  to  give  a  dovetailed 


CLASSIFICATION    AND    PREPARATION    OP   CAVITIES  119 

form,  as  illustrated  in  the  cross-section  of  an  incisor  (Fig.  78). 
In  posterior  teeth  inaccessible  to  the  straight  hand-piece  the  de- 
sired result  may  be  attained  by  using  an  inverted  cone  bur  in  the 
right-angle  hand-piece. 

When  the  walls  are  formed  the  enamel-margins  may  be  beveled 
with  a  sharp  chisel,  or,  what  is  preferable  when  properly  used,  a 
round  bur  or  stone  in  the  engine.  This  must  be  kept  under 
perfect  control  and  made  to  follow  the  margin  without  slipping 
out  of  place.  To  maintain  a  bur  in  its  proper  position  in  following 
the  margins  of  a  cavity  it  is  often  advisable  to  let  the  shank  rest 
on  a  support  or  fulcrum  formed  by  some  adjacent  surface  of  the 
enamel.  In  this  way  the  bur  may  be  accurately  guided  along  the 
margin  so  as  to  cut  at  any  desired  angle.  A  more  perfect  sym- 
metry may  be  given  to  a  margin  with  a  revolving  instrument 
like  a  bur  or  stone  than  is  possible  with  a  chisel.  This  is  particu- 
larly true  of  the  curves  in  the  cavity  outline. 

General  Considerations 

As  has  been  stated,  these  cavities  are  often  the  most  dreaded  of 
any  by  the  majority  of  operators.  That  they  present  elements 
of  difficulty  peculiar  to  themselves  is  undoubtedly  true,  but  if 
treated  on  correct  principles  they  are  in  many  respects  the  most 
satisfactory  of  all  filling-operations.  The  problem  of  anchorage  is 
exceedingly  simple  on  account  of  the  lack  of  any  stress  tending  to 
dislodge  the  filling.  The  marginal  outlines  of  the  cavity,  if  prop- 
erly formed,  are  comparatively  safe  from  recurrence  of  decay, 
through  the  fact  that  the  gum  completely  protects  the  gingival 
margin  and  the  other  margins  are  kept  clean  by  friction  of  the 
cheeks,  lips,  or  tongue.  The  open  aspect  of  these  cavities  admits 
of  an  accurate  placing  of  the  filling-material  and  a  close  scrutiny 
of  the  margins  to  detect  and  correct  any  imperfections. 

The  chief  difficulties  of  management  relate  to  forcing  the  gum 
out  of  the  way  sufficiently  to  admit  of  free  working,  to  keeping  the 
cavity  dry,  and  to  the  supposed  fact  that  these  cavities  are 
usually  more  sensitive  than  others.  As  to  the  latter  complica- 
tion, it  is  counterbalanced  both  for  the  patient  and  operator  by 
the  rapidity  with  which  such  a  cavity  can  be  prepared,  and  the 
discomfort  in  the  aggregate  is  therefore  not  much  greater  than 
with  other  cavities  of  similar  extent.  If  the  gum  has  grown 
into  the  cavity  it  can  be  forced  away  so  as  to  expose  the  gingival 


120  PRINCIPLES   AND    PRACTICE    OP    FILLING    TEETH 

margin  by  packing  gutta-percha  into  the  cavity,  allowing  it  to 
extend  over  the  margin.  This  may  be  left  a  day  or  two,  when 
the  cavity  will  be  found  freely  accessible.  The  problem  of  keep- 
ing the  cavity  dry  is  simply  a  question  of  skill  and  ''knack" 
which  may  be  acquired  by  almost  any  operator  who  will  give  a 
close  study  to  the  special  requirements  of  the  case.  With  this 
skill  once  developed  these  cavities  are  readily  brought  under 
control. 

Occlusal  Cavities  in  Bicuspids  and  Molars 

These  cavities  are  usually  the  result  of  structural  imperfections 
in  the  tooth  by  which  the  developing  islands  of  calcification, 
beginning  at  the  tips  of  the  cusps,  have  failed  to  properly  unite 
on  approaching  each  other,  leaving  a  leak  for  the  ingress  of 
foreign  matter.  The  chief  considerations  in  the  management  of 
these  cases  relate  to  the  breaking  down  of  overhanging  enamel, 
the  removal  of  decay,  the  obliteration  of  any  remaining  structural 
imperfections  in  the  way  of  fissures  extending  from  the  cavity, 
and  the  proper  retentive  form  for  the  filling. 

An  important  distinction  between  caries  occurring  in  these 
surfaces  and  that  of  other  surfaces  already  considered  is  due  to 
the  fact  that  upon  occlusal  surfaces  decay  seldom  occurs  except 
as  the  result  of  defects  in  the  enamel,  while  on  the  others  it  is 
often  found  beginning  in  perfectly  formed  enamel.  The  reason 
for  this  is  that  the  friction  of  mastication  very  largely  prevents 
the  possibility  of  decay  upon  the  occlusal  surfaces,  except  as  the 
agent  of  caries  is  harbored  in  some  crevice  or  fissure  where  the 
cleansing  process  of  mastication  cannot  reach.  On  this  account 
extension  for  prevention  is  seldom  indicated  in  occlusal  surfaces 
unless  the  drilling  out  of  all  fissures  running  from  the  cavity  may 
be  so  interpreted. 

This  problem  of  the  treatment  of  fissures  is  one  indissolubly 
linked  with  the  management  of  these  occlusal  cavities.  Many 
operators  do  not  seem  to  consider  it  necessary  to  drill  out  fissures 
unless  actual  decay  has  begun  in  them.  They  overlook  two 
things — the  difficulty  of  making  a  good  margin  to  the  filling  at 
the  intersection  of  a  fissure,  and  the  real  nature  of  the  imperfec- 
tion that  a  fissure  represents.  If  an  operator  has  any  doubt  as  to 
the  necessity  for  drilling  out  all  fissures  extending  from  a  cavity 
under  preparation,  let  him  make  a  microscopical  examination  of 
sections  of  teeth  cut  crosswise  of  a  fissure,  and  he  will  no  longer 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES  121 

hesitate.  In  many  of  these  cases  where  the  orifice  of  the  fissure 
is  so  narrow  as  scarcely  to  admit  the  finest  exploring  instrument, 
the  microscope  will  show  a  decided  imperfection  reaching  entirely 
through  the  enamel,  as  indicated  in  Fig.  79.  This  kind  of  a 
break  in  the  enamel-surface  is  a  serious  menace  to  the  tooth, 
and  no  operator  is  doing  his  duty  by  the  patient  when  he  leaves 
such  a  defect  in  connection  with  his  work.  It  is  the  minutiae 
which  count  in  dental  practice,  and  microscopic  conditions  must 
not  be  ignored. 

It  would  be  a  revelation  to  many  operators  to  turn  the  micro- 
scope upon  cases  similar  to  the  ones  they  are  treating  every  day, 
and  see  the  numberless  imperfections  which  the  unaided  eye  can- 
not detect.  One  of  these  fissures,  apparently  so  slight  as  to  be 
of  little  moment,  and  which  the  blunt  exploring  instruments  in 
common  use  in  offices  will  scarcely  penetrate,  may  be  found  large 
enough  on  microscopical  examination  to  admit  a  whole  army  of 
micro-organisms  sufficient,  if  the  conditions  be  favorable,  to 
undermine  the  tissue  in  a  few  months.  If  we  are  to  successfully 
combat  this  disease  of  dental  caries  we  must  be  observant  and 
infinitely  painstaking. 


1  ^  , 

Fig.  80.         Fig.  81.       Fig.  82.     Fig.  83. 

Another  reason  for  drilling  out  these  fissures  and  filling  them  is 
because  the  surface  of  the  tooth  is  thereby  rendered  more  perfect 
in  form.  In  almost  every  case  where  a  fissure  exists  there  will  be 
found  a  somewhat  notable  depression  in  the  enamel  leading  down 
to  it,  and  this  V-shaped  sulcus  furnishes  a  receptacle  for  the 
lodgment  of  certain  kinds  of  food  material,  to  the  annoyance  and 
discomfort  of  the  patient.  Berry  seeds  and  other  like  substances 
are  especially  prone  to  lodge  in  these  depressions,  and  comfort- 
able mastication  is  thus  interfered  with.  It  should  be  the  office 
of  the  dentist  to  correct,  if  possible,  any  faults  of  form  in  the 
teeth  he  is  operating  on,  and  this  may  readily  be  done  in  the  case 
of  fissures  by  drilling  them  out  and  building  up  the  filling  as 
illustrated  in  Fig.  80.  This  change  in  the  form  of  the  occlusal 
surface  does  not  in  any  way  detract  from  the  efficiency  of  mastica- 


122  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

tion,  because  the  biting  force  of  the  cusps  of  the  opposing  tooth 
will  be  fully  as  effective — if  not  more  effective — when  exerted 
against  a  moderate  concavity  such  as  the  surface  of  the  filling 
would  present,  as  it  will  when  brought  to  bear  upon  a  V-shaped 
depression. 

In  what  has  been  said  with  reference  to  drilling-out  fissures 
the  caution  should  be  urged  against  confusing  grooves  with 
fissures.  There  is  a  sharp  distinction  between  a  groove  which 
merely  dips  slightly  into  the  surface  of  the  enamel  without 
penetrating  it  to  the  dentin,  and  a  fissure  which  results  in  a  com- 
plete cleft  in  the  enamel.  The  groove  may  be  safely  left  except  in 
those  cases  where  the  depression  would  interfere  with  a  perfect 
margin  to  the  filling. 

The  Marginal  Outlines. — The  outlines  of  the  different  cavities 
in  the  occlusal  surfaces  will  vary  greatly  accordingly  to  the  kind 
of  tooth  and  the  particular  conditions  present  in  each  case.  The 
number  of  cusps  and  the  direction  of  the  fissures  seem  to  be  the 
most  prominent  factors  in  determining  cavity  outline,  while  the 
extent  of  decay  is  of  course  always  to  be  reckoned  with.  What 
may  be  considered  typical  cavity  outlines  are  here  illustrated  in 
the  different  teeth.  Fig.  81  shows  the  occlusal  surface  of  an 
upper  bicuspid  with  filling  in  place.  This  is  almost  universally 
the  form  for  these  teeth  where  the  slightest  decay  has  begun  upon 
the  surface,  even  if  only  one  pit  at  the  termination  of  the  central 
groove  has  been  affected.  The  reason  for  this  is  that  the  groove 
is  nearly  always  fissured  throughout  its  length,  and  even  when 
not  fissured  it  is  sufficiently  sulcate  to  prevent  the  proper  finish 
of  a  filling  against  its  intersection.  In  lower  bicuspids — particu- 
larly in  the  first — the  transverse  ridge  of  enamel  leading  from 
the  buccal  cusp  to  the  lingual  is  often  so  prominent  and  so  per- 
fect in  structure  as  to  leave  no  central  groove,  thus  dividing 
definitely  the  mesial  and  distal  pits.  In  these  cases  the  pits  may 
be  filled  separately,  as  illustrated  in  Fig.  82.  In  the  lower 
second  bicuspid  the  outline  may  sometimes  simulate  that  of  the 
upper  bicuspids,  while  in  occasional  cases  we  find  three  cusps  on 
this  surface,  necessitating  the  outline  given  in  Fig.  83.  In  the 
upper  molars  there  are  usually  two  cavities  corresponding  to  the 
central  and  distal  pits,  as  shown  in  Fig.  84,  or  the  disto-hngual 
groove  may  be  fissured  throughout  its  length,  resulting  in  an 
outline  such  as  that  in  Fig.  85.  In  cases  of  extensive  decay, 
where  the  oblique  ridge  of  enamel  between  the  central  and 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES  123 

distal  pits  is  so  seriously  undermined  as  to  jeopardize  its  sta- 
bility, it  should  be  cut  away  and  a  cavity  formed  like  the  one 
in  Fig.  86. 

It  is  sometimes  a  point  of  nice  distinction  to  determine  whether 
this  ridge  shall  be  left  standing  or  be  broken  down,  the  decision 
being  based  principally  upon  two  factors — the  extent  of  dentin 
supporting  it  and  the  depth  of  the  distal  groove.  If  it  is  not  well 
supported  by  dentin  it  will  prove  an  element  of  weakness  between 
the  two  fillings,  and  if  the  groove  is  sufficiently  deep  to  present  a 
notable  depression  at  this  point  it  will  leave  an  undesirable  form  to 
the  surface.  The  operator  must  decide  on  the  basis  of  long-con- 
tinued usage  in  the  future  rather  than  from  past  usage  or  a  tem- 
porary service.     One  condition  in  this  connection  is  calculated  to 


Fig.  84.  Fig.  85.  Fig.  86.  Fig.  87. 

mislead  an  unobservant  operator,  and  this  holds  true  as  well  of 
other  walls  on  the  occlusal  surfaces  as  of  the  one  under  considera- 
tion. The  fact  that  a  certain  wall  has  stood  without  fracture  up 
to  the  time  of  the  operation  is  often  accepted  as  an  indication  that 
it  may  safely  be  left  around  a  filling.  The  argument  is  used  that 
if  it  has  not  broken  when  surrounding  a  cavity  it  certainly  will 
not  break  when  reinforced  by  a  filling,  but  an  important  factor  in 
the  case  is  overlooked.  When  a  tooth  begins  to  decay  it  is  often 
more  or  less  sensitive  under  mastication,  and  the  patient  involun- 
tarily forms  the  habit  of  favoring  the  tooth  so  that  it  does  not 
receive  its  full  share  of  masticating  usage.  The  decay  progresses 
till  the  enamel  is  so  undermined  as  to  leave  very  weak  walls,  which 
may  stand  indefinitely  under  these  conditions,  so  far  as  the  stress 
of  mastication  is  concerned.  But  when  the  cavity  is  filled  and  the 
tooth  rendered  comfortable,  the  patient  gradually  begins  to  use  it 
again,  and  the  consequence  is,  often,  fractured  walls  when  the 
operator  had  judged  them  to  be  safe. 

The  cavity  outlines  on  lower  molars  differ  from  those  on  upper 
molars,  and  there  is  also  a  variation  between  the  lower  first  molar 
and  lower  second  molar.  The  lower  first  molar  has  five  cusps  in- 
tersected by  grooves  which  are  frequently  fissured,  thus  resulting 
in  a  cavity  outline  such  as  is  illustrated  in  Fig.  87.     Occasion- 


124  PRINCIPLES    AND    PRACTICE    OF    PILLING    TEETH 

ally  the  buccal  groove  and  the  disto-buccal  groove  are  fissured 
throughout  their  length,  which  would  result  in  the  filling  being 
carried  over  on  the  buccal  surface  to  the  full  extent  of  the  fissure. 
When* this  is  done  the  buccal  extremity  of  the  cavity  should  pre- 
sent the  form  in  Fig.  88.  The  lower  second  molar,  having  four 
cusps,  calls  for  a  cavity  outline  similar  to  that  in  Fig.  89.  The 
third  molars,  upper  and  lower,  are  so  variable  in  form  as  to  pre- 
clude the  possibility  of  suggesting  anything  like  a  uniform  cavity 
outline  in  either  of  them^  each  case  calling  for  special  considera-' 
tion  as  it  presents  itself. 

The  Cavity-Walls. — The  walls  surrounding  these  cavities  should 
be  perpendicular,  or  in  line  with  the  long  axis  of  the  tooth.  The 
pulpal  wall  or  seat  should  be  horizontal  or  flat,  and  should  join  the 
other  walls  at  right  angles  (Fig.  90).     This  is  particularly  true 


mh     m,)..6 


Fig.  88.  Fig.  89.  Fig.  90.  Fig.  91. 

of  the  mesial,  distal,  buccal,  and  lingual  extremities  of  the  cavity. 
On  account  of  the  difficulty  of  making  a  perpendicular  wall  at  the 
termination  of  a  fissure,  the  cavity  extremities  are  sometimes  left 
as  illustrated  in  Fig.  91a.  This  is  an  incorrect  form,  no  matter 
how  well  the  filling  may  be  anchored  in  other  parts  of  the  cavity. 
In  every  case  it  should  be  formed  as  in  Fig.  916.  The  reason  for 
this  is  that  the  extremities  of  the  fillings  formed  like  that  at  a  are 
likely  to  be  lifted  out  of  place  in  the  mastication  of  adhesive  mate- 
rials such  as  candies,  etc. 

The  depth  of  the  cavity  pulpally  is  governed  in  the  carious  por- 
tion by  the  extent  of  decay,  and  in  the  fissured  portions  by  the 
depth  of  the  fissure.  It  will  be  found  that  anything  short  of  a 
full  extension  to  the  depth  of  the  fissure  will  result  in  so  shallow  a 
cavity  as  to  render  the  filling-material  weak.  Numerous  failures 
of  portions  of  these  fillings  along  fissures  have  been  noted  in  con- 
sequence of  insufficient  bulk  of  material.  There  can  be  no  argu- 
ment against  deepening  the  cavity  to  the  full  extent  of  the  fissure 
from  the  fact,  as  already  stated,  that  wherever  a  fissure  exists  there 
is  no  binding  strength  to  the  tooth  throughout  its  extent.  The 
certainty  of  determining  definitely  just  when  the  bottom  of  a 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES  125 

fissure  is  reached  is  sometimes  rendered  difficult  on  account  of  the 
fine  particles  of  tooth-tissue  from  the  drill  filling  the  deepest  por- 
tion of  the  fissure  and  hiding  it  from  view.  This  may  readily  be 
overcome  by  flooding  the  cavity  with  one  of  the  essential  oils, 
which  will  cause  the  fissure  to  immediately  show  up  dark  and  pre- 
sent its  entire  outline. 

The  width  of  the  cavity  bucco-lingually  or  mesio-distally  in  the 
decayed  portion  must  be  great  enough  to  insure  strong,  well-sup- 
ported walls,  while  in  the  fissured  portion  it  must  be  governed 
somewhat  by  the  extent  of  the  sulcus  leading  down  to  the  fissure. 
The  minimum  width  in  any  case  should  be  not  less  than  one  and 
one-half  millimeters.  The  mistake  of  leaving  too  narrow  a  cavity 
relates  to  the  difficulty  of  readily  securing  adaptation  and  density 
of  filling-material  in  a  constricted  crevice,  besides  the  important 
factor  of  providing  for  a  sufficient  bulk  of  material  to  represent 
considerable  strength  on  all  surfaces  which  are  subjected  to  con- 
tinued usage. 

Technique. — All  overhanging  walls  may  be  broken  down  with 
sharp  chisels,  and  the  fissures  opened  with  drills  as  already  de- 
scribed. The  cavity  may  be  cut  to  form  with  an  inverted  cone  bur 
placed  with  its  end  looking  toward  the  pulp  and  carried  laterally 
to  the  extent  required.  In  cases  difficult  of  approach  with  the 
straight  hand-piece — particularly  on  the  lower  teeth  and  the 
upper  teeth  of  the  left  side — the  bur  may  be  used  in  the  contra- 
or  right-angled  hand-piece.  Where  the  decay  is  extensive  the 
softened  dentin  should  be  removed  with  spoon  excavators  to 
avoid  unnecessary  pulp-exposure.  The  enamel  margins  may 
be  beveled  with  a  round  bur  or  stone.  These  cavities  are  cut  to 
form  very  expeditiously,  provided  the  operator  uses  sharp  burs 
and  goes  straight  to  his  work  with  a  definite  idea  in  his  mind  as 
to  the  required  outline  and  form  of  the  cavity  before  he  begins 
cutting. 

General  Considerations 

Of  all  filling-operations  in  the  mouth  these  should  prove  the 
most  permanent  and  satisfactory  if  properly  performed.  There  is 
little  likelihood  of  a  recurrence  of  decay  around  such  fillings  unless 
the  operator  has  left  imperfections  in  his  work  which  would  invite 
failure  under  any  circumstances.  The  wear  and  tear  upon  occlu- 
sal fillings  is  sometimes  great,  but  it  is  confidently  believed  that 
with  the  plan  of  anchorage  here  outlined  ample  provision  is  made 


126  PRINCIPLES   AND    PRACTICE    OF    FILLING    TEETH 

for  sustaining  the  filling  against  severe  usage.  The  flat  base  to 
the  cavity  secures  immunity  from  movement,  and  the  perpen- 
dicular walls  leave  no  overhanging  enamel  to  be  broken  down. 
The  obliteration  of  fissures  results  in  improved  form  to  the  surface 
and  precludes  the  possibility  of  micro-organisms  finding  a  habitat 
in  this  region.  Operations  here  as  elsewhere  must  be  carefully 
planned  and  executed  throughout,  but  the  results  on  occlusal  sur- 
faces are  never  so  much  in  doubt  as  they  would  seem  to  be  in  other 
localities. 

The  Treatment  of  Softened  Dentin  in  Deep-Seated  Cavities 

In  the  preparation  of  cavities  the  operator  often  encounters  a 
problem  in  the  presence  of  a  large  mass  of  decalcified  or  partially 
decalcified  dentin  in  the  bottom  of  a  cavity  lying  over  the  pulp. 
The  treatment  of  this  softened  dentin  is  a  subject  that  has  long 
engaged  the  attention  of  operators  and  writers  on  dental  topics, 
and  the  consensus  of  opinion  seems  in  the  past  to  have  been  favor- 
able to  the  retention  of  a  considerable  portion  of  the  decalcified 
tissue  for  the  purpose,  as  stated,  of  affording  protection  to  the 
pulp.  It  has  been  argued  that  the  pulp  will  accept  more  kindly 
this  sort  of  protection  than  it  will  the  presence  of  any  foreign 
material  in  the  nature  of  filling  or  pulp-capping.  Some  writers 
have  even  advanced  the  theory  that  the  softened  dentin  would 
take  on  a  hardening  process  and  become  recalcified  when  left  in 
the  cavity  under  these  conditions,  and  protected  from  further 
external  irritation  by  a  filling. 

Without  stopping  to  go  into  the  histological  process  of  tooth- 
building  and  the  pathological  process  of  tooth-disintegration,  it  is 
safe  to  assume  that  tooth-tissue  is  not  amenable  to  any  such  a  law 
as  would  account  for  the  recalcification  of  dentin  once  decalcified, 
and  the  sooner  this  idea  is  dismissed  from  the  minds  of  our  opera- 
tors the  better  it  will  be  for  their  patients.  From  the  closest  chn- 
ical  observation  of  thoughtful  men,  and  from  recent  investiga- 
tions into  the  penetrating  effects  of  caries  of  the  teeth,  it  would 
seem  to  be  a  serious  menace  to  leave  any  considerable  quantity 
of  decalcified  dentin  under  a  filling.  Miller  has  shown  that  the 
tubuli  of  dentin  are  packed  with  micro-organisms  far  in  advance 
of  the  actual  breaking  down  of  the  tissue,  and  Dr.  J.  Leon 
Williams  has  presented  to  us  a  revelation  in  the  far-reaching 
effects  of  caries.     On  page  289  of  the  Dental  Cosmos  for  April, 


CLASSIFICATION   AND    PREPARATION    OF    CAVITIES  127 

1897,  he  presents  a  photograph,  of  which  Fig.  92  is  a  fair  rep- 
resentation, showing  how  a  tooth  may  be  affected  by  the  acid 
of  caries  to  a  depth  beyond  the  enamel,  and  reaching  very  nearly 
to  the  pulp  without  any  serious  surface  indication.  The  tooth 
was  one  in  which  "there  was  not  a  trace  of  a  cavity  to  be  seen 
on  the  external  surface."  Presumably  an  exploring  instrument 
might  have  been  passed  over  the  enamel  without 
detecting  any  imperfection,  and  yet  the  acid 
formed  by  the  mass  of  micro-organisms  lodged 
upon  the  surface  had  so  affected  the  tooth-tissue 
as  to  dissolve  out  the  cement-substance  between 
the  rods  of  enamel,  leaving  minute  canals  down 
which  the  acid  traveled  to  form  a  perceptible  cavity  fig.  92. 
at  the  junction  of  the  enamel  and  dentin,  and  also 
to  extend  its  softening  influence  some  distance  into  the  dentin  in 
the  direction  of  the  pulp. 

Here  is  an  object  lesson  to  set  even  the  most  careless  operator  to 
thinking.  If  the  acid  of  decay  may  affect  tissue  to  the  depth  indi- 
cated without  any  perceptible  external  evidence,  what  must  be 
the  condition  of  the  dentin  covering  the  pulp  when  the  process  of 
decay  has  gone  on  so  far  as  to  cause  a  complete  disintegration  of 
the  enamel  and  an  extensive  cavity  into  the  dentin?  We  can  no 
longer  trifle  with  a  disease  which  projects  its  baneful  influence  so 
far  in  advance  of  any  ocular  manifestation. 

Let  us  study  briefly  the  nature  of  this  decalcified  tisue  which 
we  are  taught  to  leave  under  our  fillings.  It  has  in  large  part 
been  disorganized;  it  is  packed  with  micro-organisms  and  infil- 
trated with  poisons.  If  we  seal  it  under  a  filling  we  have  confined 
within  the  tooth  just  so  much  of  a  menace  to  the  life  and  comfort 
of  the  pulp.  It  will  not  do  to  say  that  the  micro-organisms  thus 
inclosed  are  rendered  harmless  on  account  of  cutting  off  their  out- 
side sustenance  and  allowing  them  to  die.  A  mass  of  dead  micro- 
organisms is  by  no  means  inert.  In  fact,  scientists  are  telling  us 
that  from  the  dead  bodies  of  micro-organisms  come  the  most  viru- 
lent poisons.  Neither  will  it  do  to  assume  that  by  the  application 
of  an  antiseptic  to  the  cavity  we  overcome  the  difficulty.  We  may 
destroy  more  or  less  perfectly  the  micro-organisms  in  the  dentin, 
but  we  are  not  at  all  certain  of  thereby  destroying  the  poisons. 
In  experimental  work  micro-organisms  are  killed  with  chemical 
agents,  and  then  from  the  mass  thus  destroyed  the  poisons  are 
extracted.     It  would  seem  to  be  a  fruitful  field  of  research  for 


128  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

some  scientist  to  determine  the  kind  of  agent  required  to  destroy 
the  micro-organism  and  at  the  same  time  neutraHze  its  poison. 
But  what  concerns  us  most  in  the  consideration  of  the  present 
subject  is  that  by  following  the  generally  accepted  teaching  of  the 
past  in  the  management  of  decalcified  dentin  we  are  simply  con- 
fining in  intimate  proximity  to  the  pulp  a  mass  of  material  which 
is  peculiarly  calculated  to  poison  the  pulp  to  death.  And  this  is 
precisely  what  occurs  in  many  of  those  vague  cases  where  the 
pulp  has  ''unaccountably"  died  under  a  filling  without  an  ex- 
posure. The  greatest  surprise  is  that  more  pulps  have  not  died 
from  this  treatment,  and  it  is  accounted  for  only  on  the  ground 
that  pulps  are  sometimes  exceedingly  tenacious  of  life,  and  pro- 
tect themselves  against  the  inroads  of  the  poisonous  process  by 
throwing  out  a  deposit  of  secondary  dentin.  Even  in  those  cases 
where  the  pulp  finally  triumphs  over  the  evil  influence,  the 
operation  of  filling  is  quite  frequently  succeeded  by  an  extended 
period  of  sensitiveness  which  is  the  direct  result  of  the  irritating 
influence  of  the  infiltrated  dentin.  In  almost  every  instance 
where  softened  dentin  is  left  in  the  cavity  as  a  source  of  pulp 
protection,  or  to  prevent  shock  from  thermal  changes,  it  defeats 
the  very  object  for  which  it  was  left.  This  mass  of  tissue  is 
exceedingly  irritable.  It  is  more  sensitive  to  impressions  of  all 
kinds,  whether  thermal,  chemical,  or  mechanical,  than  is  normal 
dentin.  It  would  therefore  seem  theoretically  that  the  less  we 
left  of  this  infected  tissue  under  a  filling  the  more  comfortable 
would  the  tooth  remain  after  the  operation,  and  this  very  fact 
is  amply  borne  out  by  clinical  observation.  In  a  somewhat 
close  study  of  this  question  it  has  been  noted  that  in  those  cases 
where  a  radical  removal  of  all  softened  dentin  has  been  effected 
there  is  seldom  any  complaint  of  subsequent  sensitiveness. 

This  does  not  imply  that  we  must  carelessly  expose  pulps  by 
wantonly  slashing  away  at  every  cavity  that  presents.  No  opera- 
tor should  expose  a  pulp  if  it  can  be  safely  avoided.  In  working 
around  a  pulp  under  these  conditions,  as  has  already  been  inti- 
mated, a  spoon-shaped  excavator  should  be  used  to  avoid  needless 
exposure.  The  excavator  should  be  very  thin  and  sharp,  so  as  to 
peel  up  the  leathery  dentin  with  the  utmost  delicacy  and  the  ex- 
penditure of  very  little  force. 

The  rules  to  govern  the  operator  in  the  management  of  decalci- 
fied dentin  may  be  summarized  as  follows:  Remove  thoroughly 
all  decalcified  tissue  in  every  instance  where  its  removal,  will  not 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES  129 

result  in  exposure  of  the  pulp.  In  those  cases  where  it  extends  to 
the  pulp  remove  all  that  can  safely  be  done  short  of  actual  ex- 
posure, and,  if  large  masses  of  decomposing  tissue  surround  any 
portion  of  the  pulp,  remove  even  if  it  causes  exposure.  The  pulp 
will  be  safer  under  a  capping  of  foreign  material  than  when  sub- 
jected to  the  influence  of  this  infected  and  poisonous  mass. 
Stained  dentin  is  not  necessarily  infected  dentin.  If  hard  and 
flint-like  it  may  be  allowed  to  remain,  even  if  slightly  discolored. 
While  the  exact  results  of  the  application  of  medicaments  to 
decalcified  dentin  may  be  as  yet  somewhat  undetermined,  it 
would  seem,  with  our  present  knowledge  on  the  subject,  to  be  a 
wise  precaution  to  flood  all  cavities  containing  any  such  tissue 
with  an  antiseptic  previous  to  filling.  We  must  also  protect  the 
pulp  from  impingement  in  those  cases  where  the  partition  between 
the  cavity  and  the  pulp  is  so  thin  as  to  be  compressible  under  the 
force  of  impact  by  the  plugger  in  condensing  a  metal  filling,  or 
where  there  seems  to  be  danger  from  thermal  impressions.  For 
this  purpose  a  non-irritating  cement  is  indicated  as  an  inter- 
mediate between  the  filling  and  the  pulpal  wall,  but  this  cement 
must  not  be  built  up  in  such  bulk  as  to  render  the  metal  filling 
too  thin  for  strength. 

Hypersensitive  Dentin 

This  is  a  subject  which  has  been  more  or  less  prominently  before 
the  profession  ever  since  teeth  began  to  be  filled,  and  yet  it  would 
sometimes  seem 'to  be  little  nearer  a  solution  of  the  problem  than 
when  it  was  first  discussed.  This  is  partly  because  there  are  so 
'  many  varying  aspects  of  the  question,  and  because  no  sovereign  or 
universal  remedy  can  ever  be  suggested  by  which  uniform  results 
may  be  obtained;  but  possibly,  more  than  all  else,  because  the 
very  thing  most  essential  to  success  in  meeting  the  trouble  is 
something  that  cannot  well  be  taught.  It  relates  to  a  quick 
perception  on  the  part  of  the  operator  as  to  the  real  diflSculty 
with  each  case  which  presents,  and  to  the  most  active  ingenuity 
in  meeting  the  particular  issue  involved.  In  many  instances  it 
would  seem  to  be  the  dentist  who  needed  treatment  instead  of 
the  dentin.  In  others  the  patient  requires  operating  on  in  ad- 
vance of  the  tooth. 

To  present  this  subject  in  anything  approaching  a  systematic 
order,  it  will  be  necessary  to  classify  somewhat  the  conditions 
which  may  confront  the  operator.     These  conditions  relate  to  the 


130  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

varying  temperaments  of  patients,  and  to  the  differences  in  char- 
acter of  sensitive  teeth.  Patients  require  the  closest  study  in 
order  to  know  how  best  to  approach  them  to  dispel  the  common 
dread  of  the  dental  chair,  and  no  operator  is  suited  to  the  practice 
of  dentistry  who  ignores  this  important  feature  of  his  work.  It 
has  been  too  long  a  crying  disgrace  to  dentistry  to  permit  the 
impression  to  prevail  among  all  classes  that  dental  operations  are 
necessarily  so  very  painful.  Some  of  the  old-time  heroic  opera- 
tors (blessed  be  their  memory)  are,  in  this  one  particular,  blamable 
that  they  too  often  entirely  ignored  the  sensibilities  of  their  pa- 
tients, and  treated  them  as  if  they  were  mere  blocks  of  wood.  We 
of  to-day  are  reaping  the  results  of  some  of  this  early  sowing  in  the 
almost  universal  dread  with  which  patients  approach  the  dental 
chair,  owing  largely  to  the  traditional  story  of  its  tortures.  In 
the  modern  dental  practice,  properly  conducted,  there  is  little 
to  justify  this  dread,  and  the  dentists  of  to-day  should  do  all  in 
their  power  to  overcome  the  impressions  formed  by  past  years 
of  mismanagement. 

In  studying  the  characteristics  of  our  patients  in  this  regard  it 
might  be  possible  to  make  many  minute  classifications  as  to  con- 
duct and  temperament,  but  for  present  purposes  a  more  general 
consideration  must  suffice. 

First  as  a  class  may  be  noted  those  of  a  highly  wrought,  nervous 
temperament,  who  are  by  nature  sensitive  to  impressions  of  all 
kinds,  whether  physical  or  mental.  This,  when  augmented  by 
environment  or  occupation,  creates  a  condition  which  calls  for  the 
keenest  perception  on  the  part  of  the  dentist,  both  as  to  manage- 
ment of  the  patient  and  manipulation  of  the  teeth.  They  are 
usually  professional  men  or  women — artists,  musicians,  sculptors, 
or  Hterary  people — and,  fortunately  for  us,  they  are  generally 
individuals  of  a  high  order  of  intelligence.  They  are  quick  in 
their  perceptions  and  are  appreciative  of  skillful  service.  No 
dentist  of  mediocre  attainments  need  hope  for  an  extended  prac- 
tice among  this  class,  and  yet,  if  managed  by  a  master  hand,  they 
prove  a  most  desirable  clientele.  The  essentials  in  meeting  these 
patients  relate  to  a  thorough  mastery  of  the  minutest  details  of 
the  work  in  hand,  and  a  quiet  but  rapid  execution  of  all  ma- 
nipulative procedures.  There  must  be  no  false  movements,  and 
no  lapses  of  the  closest  application.  To  accomplish  the  greatest 
good  all  work  must  be  done  on  the  high-pressure  principle.  A 
patient  like  this  will  bear  to  be  hurt  for  one  short  moment 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES  131 

provided  something  definite  be  accomplished  in  that  moment, 
but  will  not  tolerate  unskillful  puttering.  Every  hne  of  pro- 
cedure must  be  carefully  studied  by  the  operator  in  advance, 
so  that  he  knows  precisely  what  he  is  going  to  do  before  he 
attempts  to  do  it.  Any  awkward  fumbling  in  the  manipulation 
is  instantly  recognized  by  the  patient,  and  confidence  is  to  that 
extent  destroyed.  The  utmost  delicacy  of  touch  should  be 
cultivated,  and  this  complemented  by  firmness  of  force  wherever 
force  is  indicated.  Short  sittings  must  be  assigned,  and  the  great- 
est possible  measure  of  accomplishment  attained  during  the  time 
the  chair  is  occupied.  In  brief,  this  type  of  individual  demands 
of  a  dentist  the  exercise  of  his  keenest  wits,  and  to  operate  to 
the  best  advantage  he  must  operate  on  a  tension  keyed  to  the 
highest  pitch.  It  is  therefore  well  that  all  our  patrons  are  not 
of  this  variety,  and  yet,  as  has  been  intimated,  they  prove  a  savor- 
ing lump  to  the  rank  and  file  and  are  in  many  ways  a  desirable 
class.  .  They  stimulate  an  operator  to  his  best  achievements,  and 
reward  him  with  an  intelligent  appreciation  of  all  that  he  accom- 
plishes for  them. 

Another  class  of  patients  consists  of  large,  robust,  healthy  indi- 
viduals who  are  by  nature  cowardly  when  it  comes  to  the  infliction 
of  physical  discomfort.  They  may  be  brave  enough  about  other 
affairs  of  life,  but  it  would  sometimes  seem  that  the  larger  they  are 
in  physical  proportions  the  smaller  they  are  in  courage  to  take  the 
dental  chair.  There  is  no  moral  suasion  that  can  be  used  on  these 
people  to  make  good  patients  of  them.  The  only  hne  of  pro- 
cedure is  to  avoid  as  far  as  possible  giving  pain  by  the  use  of 
obtundents,  or  by  employing  plastic  fillings  and  temporizing  to 
keep  the  teeth  comfortable,  with  the  hope  that  eventually  we 
may  in  some  degree  overcome  their  dread  suflB.ciently  to  accom- 
phsh  more  permanent  results.  If  we  undertake  anything  Hke 
thorough  work  at  the  outset,  we  simply  drive  them  away  from 
the  dental  office  to  allow  the  teeth  to  decay  past  all  recovery. 
Then  when  toothache  assails  them  they  seek  out  some  dentist 
who  gives  gas,  and  that  is  the  end  of  that  chapter. 

Another  class  relates  to  those  effeminate  irresponsible  indi- 
viduals who  have  no  stamina  of  any  kind,  physical  or  mental,  and 
who  require  a  strong  guiding  hand  to  control  them  in  any  emer- 
gency of  life.  They  are  usually  forced  to  go  to  the  dentist  either 
by  pain  or  by  the  admonition  of  friends,  and  their  successful  man- 
agement calls  for  a  rare  combination  of  gentleness  and  firmness. 


132  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

They  must  of  course  be  assured  that  the  dentist  will  not  hurt 
them  more  than  is  absolutely  necessary,  but  they  should  also  be 
given  to  understand  that  they  must  nerve  themselves  against  any 
pain  that  is  necessary.  A  dentist  should  never  be  harsh  with  any 
patient,  but  with  this  particular  class  it  is  sometimes  salutary  to 
be  stern  and  to  permit  of  no  trifling.  If  much  sternness  is  de- 
manded during  an  operation,  it  should  invariably  be  tempered 
before  the  patient  vacates  the  chair  with  the  kindest  possible  tone 
of  voice,  to  the  end  that  the  patient  leaves  the  office  with  the 
conviction  that  the  dentist  is  kind  of  heart  and  is  severe  only  for 
the  patient's  good.  A  series  of  dental  operations  for  an  individual 
of  this  type  often  proves  of  the  utmost  disciphnary  benefit, 
provided  the  operator  is  an  acute  reader  of  character  and  knows 
just  when  to  be  firm  and  when  to  be  gentle. 

He  should  be  quick  to  detect  the  difference  between  simulated 
pain  and  real  pain,  from  the  fact  that  these  patients  are  much 
given  to  protesting  even  when  there  is  no  occasion  for  it.  A 
simple  pressure  of  an  excavator  on  the  enamel  of  a  sound  tooth 
is  as  likely  to  cause  them  to  flinch  as  if  a  mass  of  sensitive  dentin 
were  being  removed,  and  no  self-respecting  operator  will  long 
allow  himself  to  be  made  the  victim  of  this  kind  of  folly.  He 
should  have  the  issue  out  with  them  immediately  on  the  detection 
of  such  imposition,  and  give  them  to  understand  that  he  is  neither 
to  be  deceived  nor  trifled  with.  But  the  moment  it  becomes 
necessary  to  give  real  pain  he  should  be  the  very  essence  of 
gentleness  and  forbearance,  and  do  all  in  his  power  to  help  the 
patient  over  the  painful  points.  In  this  way  he  will  not  only  pre- 
vent imposition  in  the  future,  but  will  establish  confidence  in  the 
mind  of  the  patient  that  he  is  sohcitous  only  for  his  patron's 
welfare.  Absolute  honesty  of  conviction  and  conduct,  together 
with  tact  in  its  fulfillment,  is  the  keynote  of  success  with  these, 
as  in  fact  with  all  other  patients. 

The  management  of  children  in  the  dental  office  is  another  con- 
sideration worthy  of  the  closest  study.  A  child  never  should  be 
given  pain  if  possible  on  the  occasion  of  its  first  visit  to  the  dentist. 
In  fact,  the.  infliction  of  pain  should  be  as  largely  avoided  as  may 
be  till  a  feeling  of  harmony  and  confidence  has  been  established 
between  the  httle  patient  and  the  operator.  A  child  should  be 
received  in  the  operating-room  with  a  cheery  smile,  as  if  the 
affairs  of  the  world  were  very  bright  on  that  particular  occasion, 
and  that  a  visit  to  the  dental  office  was  not  such  a  terribly  serious 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES  18::5 

thing  after  all.  Unfortunately,  children  usually  come  to  the  den- 
tist with  more  or  less  apprehension,  owing  to  the  traditional  table 
talk  about  the  horrors  of  the  dental  chair.  It  is  the  prime  func- 
tion of  the  dentist  to  dispel  this  idea,  and  he  who  has  kindness,  . 
tact,  and  good  judgment  can  work  wonders  in  this  direction  on 
that  momentous  first  visit.  But  he  must  have  a  love  of  children 
inherent  in  his  heart  or  he  cannot  hope  to  succeed.  He  who  does 
not  love  children  would  better  direct  them  to  some  one  who  does, 
because  of  a  certainty  they  will  prove  a  constant  source  of  annoy- 
ance to  him,  and  he  will  accomplish  little  else  with  them  than  to 
increase  their  dread  and  distaste  of  dental  operations. 

A  child  should  never  be  deceived  by  a  dentist  under  any  pretext 
whatever,  and  yet  it  is  not  well  to  make  prominent  the  fact  that  it 
is  going  to  be  necessary  to  inflict  pain.  The  dentist  should  lead 
gradually  up  to  any  painful  operation  by  a  series  of  dexterous 
and  careful  manipulations  about  the  teeth,  and  a  running  talk 
with  the  patient  upon  the  contingencies  of  the  case  from  a  child's 
point  of  view.  The  thing  of  first  importance  is  to  establish  confident 
and  cordial  relations  with  the  patient,  and  when  this  is  once 
attained  the  operator  can  accomplish  really  wonderful  results, 
even  upon  the  youngest  child.  Tact,  kindness,  the  alleviation 
of  pain  when  the  patient  is  suffering,  lack  of  deception,  and  short 
sittings,  all  harmonize  into  the  successful  management  of  chil- 
dren's teeth. 

If  the  control  of  the  different  classes  of  patients  herein  briefly 
outlined  is  studied,  the  problem  of  sensitive  dentin  is  many  de- 
grees more  than  half  solved;  in  fact,  it  would  sometimes  seem  as  if 
this  bugbear  were  greatly  exaggerated  by  the  profession.  A  care- 
ful observation  of  the  causes  which  lead  the  average  patient  of 
to-day  to  dread  the  dental  chair  in  a  properly  conducted  practice 
will  reveal  the  fact  that  it  is  as  much  the  concomitant  annoyances 
of  the  rubber  dam,  the  separator,  the  mallet,  the  use  of  disks  or 
finishing  strips,  the  grating  of  excavators,  or  the  vibration  of  rotary 
instruments,  as  it  is  the  infliction  of  any  real  pain  in  the  cutting  of 
sensitive  dentin.  And  yet  there  are  many  unmistakable  cases 
of  actual  hypersensitiveness  that  must  be  recognized  and  dealt 
with. 

The  treatment  of  these  cases  relates  to  proper  instrumentation 
and  proper  medication — the  former  fully  as  important  as  the 
latter.  The  dexterous  use  of  instruments  will  reduce  the  number 
of  cases  requiring  medication  to  a  very  narrow  limit,  and  it  is 


134  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

strongly  urged  that  a  most  careful  study  be  made  of  the  manner  of 
approaching  hypersensitive  dentin  so  as  to  remove  it  with  the 
least  possible  discomfort. 

Cavities  may  be  divided  more  or  less  perfectly  into  classes,  each 
class  presenting  its  own  pecuharities  of  sensitiveness,  and  suggest- 
ing the  method  of  treatment  best  suited  for  it.  A  large  class  con- 
sists of  those  cases  where  there  is  a  mass  of  softened  dentin  nearly 
filling  the  cavity,  with  much  overhanging  enamel.  If  an  instru- 
ment is  thrust  into  this  leathery  mass  at  almost  any  point  it  is 
sensitive.  If  there  is  any  manipulation  of  it  along  the  surface  it 
gives  pain.  The  first  thing  to  do  is  to  break  down  all  overhanging 
enamel,  so  that  the  dentin  lies  as  fully  exposed  as  may  be  before 
any  attempt  is  made  to  remove  it.  Then,  with  a  thin-bladed 
excavator,  whetted  keenly  sharp,  the  whole  mass  should  be  re- 
moved as  completely  as  possible  with  one  sweep.  This  can  ordi- 
narily be  done  with  little  pain  if  the  blade  of  the  excavator  be 
sunk  at  one  side  of  the  leathery  mass  to  its  depth,  and  the  mass 
rolled  out.  The  tissue  immediately  under  this  softened  layer  is 
usually  not  so  sensitive  as  the  surface,  and  the  remaining  cutting 
to  give  form  to  the  cavity  is  seldom  appreciably  painful.  But,  in 
case  there  is  sensitiveness,  it  can  be  controlled  by  dehydrating  the 
tissue  with  alcohol,  followed  by  warm  air.  If  the  rapid  dehydra- 
tion causes  pain  it  should  be  preceded  by  ninety-five  per  cent, 
phenol  after  which  the  cavity  can  be  dried  with  little  discomfort. 
Dr.  N.  S.  Jenkins  has  suggested  that  phenol  to  be  most  effective  for 
reheving  sensitiveness  should  be  heated,  and  Dr.  Geo.  Gow 
recommends  as  the  best  means  of  heating  it  to  pack  the  cavity 
with  cotton  saturated  with  the  agent  and  apply  to  it  a  hot 
burnisher. 

In  the  application  of  any  medicament  to  a  cavity  the  fact  should 
be  made  prominent  to  the  patient  that  the  drug  is  being  used  for 
the  purpose  of  relieving  the  pain.  This  of  itself  reassures  the  pa- 
tient, and  is  often  of  more  benefit  in  a  psychological  way  than  is 
the  specific  action  of  the  drug. 

Another  class  of  cavity  calling  for  treatment  peculiar  to  the 
case  in  hand  consists  of  those  shallow  oval  cavities,  particularly  on 
the  labial  or  buccal  surfaces,  where  there  is  little  softened  dentin, 
but  merely  a  corroded  and  reasonably  hard  surface  to  the  cavity. 
Most  of  the  cutting  must  be  done  in  comparatively  firm  tissue,  for 
the  purpose  of  giving  retentive  form  to  the  cavity  and  to  secure 
perfect  margins.     These  cavities  are  much  dreaded  by  dentists  on 


CLASSIFICATION    AND    PREPARATION    OF    CAVITIES  135 

account  of  their  traditional  sensitiveness,  but  by  a  careful  observa- 
tion it  will  be  found  that  with  very  many  of  them  the  sensitive- 
ness exists  only  on  the  surface.  The  first  touch  is  the  worst.  If, 
when  the  rubber  dam  is  applied  and  the  cavity  dried,  the  opera- 
tor will  take  a  sharp  inverted  cone  bur,  as  already  advised  for 
forming  these  cavities,  and,  with  the  engine  revolving  rapidly, 
place  the  end  of  the  bur  in  the  deepest  portion  of  the  cavity,  and 
just  at  that  moment  speak  to  the  patient  in  a  reassuring  tone  of 
voice,  and  while  speaking  at  once  penetrate  this  outer  sensitive 
crust  with  the  bur,  the  worst  of  that  cavity  preparation  is  over. 
The  bur  may  then  be  carried  laterally,  its  end  to  the  full  depth  of 
the  cavity  and  cutting  with  its  sides,  causing  little  pain.  The 
active  cutting  in  the  deep  portion  of  the  cavity  is  less  painful  than 
would  be  the  slightest  manipulation  on  the  surface.  The  sur- 
face should  therefore  be  left  alone  as  largely  as  possible  till  the 
sides  of  the  bur  have  undermined  it  in  advance.  In  the  successful 
management  of  these  cases  there  must  be  no  hesitation  and  no 
half  measures.  The  operator  must  know  definitely  what  he  is 
going  to  do,  and  then  do  it  with  the  greatest  dispatch  and  pre- 
cision. It  requires  a  masterly,  vigorous  hand,  wielded  with  the 
utmost  delicacy. 

Sometimes  the  surface  sensitiveness  of  these  cavities  may  be 
greatly  reduced  by  medication  and  desiccation.  For  this  purpose 
phenol,  followed  by  alcohol  evaporated  with  warm  air,  seems 
to  give  the  best  results  with  the  least  accompanying  discomfort. 
The  application  of  drugs  which  cause  more  pain  on  contact  with 
the  dentin  than  would  the  preparation  of  the  cavity  itself  should 
be  discontinued,  unless  for  those  exceptional  individuals  who  seem 
to  prefer  any  kind  of  pain  rather  than  pain  given  by  an 
instrument. 

With  very  many  cavities  it  will  be  found  that  the  sensitiveness 
is  confined  to  one  or  two  small  areas,  which  if  dexterously  under- 
mined or  cut  through  quickly  will  solve  the  problem  in  short  order. 
When  an  operator  discovers  in  a  cavity  one  of  these  sensitive 
points  he  should  avoid  manipulating  it,  unless  with  a  definite 
attempt  at  its  complete  removal. 

The  last  class  of  cavities  for  consideration  relates  to  those  occa- 
sional cases  where  the  teeth  are  in  an  unmistakably  hypersensitive 
condition,  where  the  slightest  pressure  upon  a  cavity  results  in 
pain,  and  where  anything  like  thorough  manipulation  is  out  of  the 
question.     The  best  course  to  pursue  is  to  employ  as  a  tempo- 


136  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

rary  expedient  till  the  sensitiveness  subsides  some,  filling-mate- 
rial such  as  cement,  which  may  be  used  without  the  thorough 
preparation  of  the  cavity  required  for  the  metals. 

In  the  use  of  cement  for  the  sealing  of  cavities  temporarily, 
the  common  error  is  made  of  allowing  it  to  remain  too  long, 
till  it  is  so  disintegrated  as  to  defeat  the  object  for  which  it  was 
used.  If  a  cement  filling  be  placed  in  a  very  sensitive  cavity 
so  as  to  perfectly  seal  it  from  external  irritants,  and  allowed  to 
remain  from  three  to  four  months,  it  will  be  found  on  removal  that 
the  cavity  can  be  prepared  properly  with  little  pain.  As  much  of 
the  decay  as  possible  should  be  removed  from  the  cavity  before  the 
cement  is  inserted,  and  when  the  cement  is  to  be  drilled  out  the 
rubber  dam  should  be  applied  and  the  cavity  kept  free  from  mois- 
ture till  prepared  as  desired.  In  those  cases  where  it  seems  impos- 
sible to  remove  the  decay  in  the  first  instance  it  is  often  advanta- 
geous to  seal  a  pledget  of  cotton  saturated  with  the  oil  of  cloves  in 
the  cavity  for  three  or  four  days,  when  the  decay  can  ordinarily  be 
rolled  out  of  the  cavity  with  sharp  excavators. 

The  whole  question  of  the  management  of  sensitive  dentin, 
except  in  the  rare  instances  just  indicated,  resolves  itself  to  the  fol- 
lowing summary :  Manipulative  skill  on  the  part  of  the  operator, 
tact  in  knowing  how  to  control  the  different  temperaments  among 
our  patients,  and  the  invariable  use  of  the  keenest,  sharpest 
instruments. 


CHAPTER  VI 

FILLING-MATERIALS 

A  proper  consideration  of  the  filling-materials  in  use  at  the 
present  time  leads  us  at  once  to  the  conviction  that  we  have  no 
ideal  material  with  which  to  fill  teeth.  We  have  materials  which 
answer  the  purpose  reasonably  well  under  certain  conditions,  but 
no  material  which  answers  well  under  all  conditions.  It  is  there- 
fore important  that  in  the  consideration  of  this  question  we  study- 
somewhat  carefully  the  characteristics  of  the  different  materials 
and  the  indications  for  or  against  their  use  under  the  varying  con- 
ditions found  in  the  mouth.  This  must  be  done  with  the  fact 
constantly  in  mind  that  no  rigid  or  invariable  rule  may  be  laid 
down  for  the  operator  to  follow  in  every  case  in  the  selection  of  his 
material.  He  must  exercise  his  best  judgment  on  the  basis  not 
only  of  expediency,  but  of  the  history  of  the  various  materials 
under  long-continued  service. 

Gold  and  Its  Combinations 

Of  all  the  materials  yet  introduced  for  filling  teeth,  gold  must 
be  acknowledged  the  peer.  When  properly  understood  and  prop- 
erly manipulated,  under  conditions  favorable  to  its  use,  it  is  one 
of  the  most  permanent  materials  we  possess.  It  is  imperious  in 
its  requirements,  as  are  all  things  worthy,  and  he  who  would  get 
the  most  from  its  use  must  adequately  acquaint  himself  with  its 
characteristics.  These  once  understood,  and  the  necessary  skiU 
developed  to  master  the  details  of  its  manipulation,  the  operator  is 
equipped  with  a  material  which  is  more  reliable  than  any  other, 
and  more  definite  in  results. 

Its  chief  advantages  consist  in  the  fact  that  it  may  be  made  suf- 
ficiently hard  to  withstand  the  wear  of  mastication;  that  it  is  not 
acted  on  chemically  by  the  fluids  of  the  mouth  so  as  to  change 
color  or  disintegrate;  that  it  remains  stationary  in  form  when 
properly  condensed,  and  that  it  is  uniform  in  its  behavior  when 
subjected   to   uniform   methods  of  manipulation.     This  latter 

137 


138  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

quality  is  really  of  much  greater  importance  than  a  superficial  con- 
sideration would  suggest.  It  enables  the  operator  to  attain  with  it 
definite  results,  year  after  year.  It  will  do  to-day  precisely  what 
it  did  the  day  before,  or  what  it  did  a  year  ago.  This  is  not  true 
of  most  other  filling-materials,  or  at  least,  if  it  is  true,  the  re- 
quirements for  maintaining  uniformity  in  the  others  are  vastly 
more  intricate  and  not  so  readily  comprehended  as  with  gold. 

When  it  is  stated  that  uniform  results  may  always  be  obtained 
with  gold,  reference  is  made  solely  to  its  physical  behavior.  It  is 
not  intended  to  imply  that  teeth  are  uniformly  saved  by  its  use, 
even  when  it  is  manipulated  in  the  best  manner.  There  are  ex- 
traneous factors  entering  into  the  salvation  or  loss  of  filled  teeth 
entirely  apart  from  the  intrinsic  merits  of  the  material  with  which 
they  are  filled,  and  gold  cannot  be  exempted  from  these  conditions. 
But  it  has  a  greater  range  of  qualities  entitling  it  to  respect  as  a 
saver  of  teeth  than  any  other  one  material,  and  the  thorough 
understanding  of  it  should  be  the  aim  of  every  practitioner. 

Its  disadvantages  may  be  said  to  consist  chiefly  in  the  fact  that 
it  is  somewhat  exacting  in  its  demands  upon  the  operator;  that  it 
cannot  be  manipulated  successfully  under  moisture;  that  its  color 
renders  it  conspicuous  for  anterior  teeth,  particularly  in  individuals 
of  certain  types,  and  that  it  is  a  conductor  of  thermal  changes. 
Another  objection  which  must  be  considered  in  some  patients  is 
the  length  of  time  necessary  for  its  insertion,  with  its  correspond- 
ing tax  on  the  individual,  and  its  relative  cost;  though  the  fact 
should  be  strongly  noted  that  a  thorough  mastery  of  the  material 
by  the  operator  will  reduce  much  of  this  within  the  limits  of  tol- 
erance. This  is  particularly  true  when  gold  is  used  in  the  form  of 
inlays. 

Nor  must  the  claim  of  its  exacting  nature  be  held  in  too  high 
esteem  as  a  disadvantage.  This  very  requisite  on  the  part  of  gold 
has  done  more  than  any  other  one  thing  in  developing  the  skill  of 
the  dental  profession  to  its  present  standard  of  excellence.  Had 
it  not  been  for  gold,  or,  in  other  words,  had  all  our  filling-materials 
been  of  a  plastic  nature,  dentistry  never  would  have  developed  the 
brilliant  manipulators  who  have  graced  its  ranks.  Gold  is  the 
stimulative  astringent  of  the  dental  profession,  keeping  our  opera- 
tors keyed  up  to  the  highest  point  of  proficiency  by  reason  of  its 
imperious  demands  upon  their  ability.  A  good  gold-worker  is 
enabled  to  perform  all  other  kinds  of  dental  service  in  a  creditable 
manner  as  the  result  of  his  skill  acquired  in  the  manipulation  of 


FILLING-MATERIALS  139 

gold,  and  this  sort  of  training  has  been  the  saving  grace  of 
dentistry. 

Too  many  sins  which  belonged  properly  elsewhere  have  been 
laid  at  the  door  of  gold.  Men  have  attemped  its  use  without  a 
sufficiently  developed  skill,  or  without  a  proper  understanding  of 
its  necessities.  They  have  ignored  its  physical  properties  and  its 
peculiar  demands.  Other  men  have  essayed  with  it  the  impossi- 
ble, and  then  attributed  their  failures  to  the  material,  thus  laying 
gold  unjustly  at  fault. 

The  fact  that  gold  cannot  be  successfully  used  under  moisture 
is  neither  an  unmixed  evil  nor  altogether  a  disadvantage,  when 
viewed  in  the  light  of  the  greatest  perfection  of  results  in  our 
work.  No  filling,  of  whatever  material,  can  be  inserted  under 
moisture  as  perfectly  as  if  the  cavity  were  dry,  and  this  necessity 
of  gold  simply  increases  our  care  and  leads  to  greater  certainty  of 
results.  It  has  also  made  us  more  expert  in  maintaining  dryness 
of  teeth  to  be  operated  on. 

The  objection  of  color  is  a  real  one  in  many  instances,  and  the 
vulgar  display  of  gold  in  the  mouths  of  the  American  people  is 
greatly  to  be  deplored.  But  this  may  largely  be  overcome,  and 
the  artistic  sense  of  observers  less  seriously  offended  than  it  is 
without  an  abandonment  of  gold  in  the  anterior  teeth,  A  close 
study  of  the  question  will  reveal  the  fact  that  gold  is  much  more 
objectionable  in  some  mouths  than  in  others.  In  certain  in- 
dividuals a  well-finished  gold  filling,  beautifully  poHshed  without 
being  burnished  so  as  to  ghsten,  is  not  at  all  conspicuous,  even 
in  an  incisor,  and  not  an  offense  to  the  esthetic  taste  of  the  most 
exacting.  In  other  individuals  a  gold  filling  in  the  anterior  part 
of  the  mouth  is  at  best  an  eyesore,  and  some  other  material  should 
be  used. 

The  difference  in  the  effect  of  gold  upon  the  appearance  of  indi- 
viduals relates  principally  to  the  temperament  and  complexion  of 
the  patient,  as  well  as  to  an  esthetic  sense  on  the  part  of  the  opera- 
tor, which  may  enable  him  to  give  his  fillings  artistic  forms.  The 
latter  consideration  should  be  carefully  studied  by  every  operator, 
to  the  end  that  gold  filhngs  in  the  future  should  not  be  allowed  to 
offend  so  glaringly  as  in  the  past,  particularly  in  those  instances 
where  offense  is  not  necessary.  As  to  complexion,  it  will  be  found 
that  decided  blondes  will  tolerate  gold  in  their  anterior  teeth  with 
less  objection  than  will  brunettes.  In  fact,  the  color  of  gold  har- 
monizes so  well  with  the  former  that  if  the  filling  is  well  inserted 


140  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

there  is  nothing  to  offend  the  eye  at  a  distance  of  several  feet. 
On  the  other  hand,  a  gold  filhng  in  the  mouth  of  a  brunette  be- 
comes at  once  conspicuous  and  objectionable.  It  is  completely 
out  of  harmony  with  the  features,  and  should  never  be  tolerated 
except  under  circumstances  of  the  most  urgent  necessity.  This 
necessity  seldom  exists,  in  view  of  the  fact  that  we  have  a  material 
at  hand  which  makes  a  filling  scarcely  discernible  in  these  cases  at 
a  distance  of  ordinary  conversation.  This  relates  to  a  combina- 
tion of  gold-and-platinum  which,  under  its  proper  head,  will  be 
considered  in  detail.  The  various  gradations  from  brunette  to 
blonde  may  be  met  with  gold-and-platinum  by  using  the  different 
numbers  as  they  come  to  us  from  the  manufacturer,  so  that  fill- 
ings may  be  made  which  will  not  be  conspicuous,  and  every  opera- 
tor should  acquaint  himself  with  this  material.  The  introduc- 
tion of  porcelain  inlay  work  and  the  silicate  cements  also  presents 
another  method  by  which  artistic  results  for  anterior  teeth  may 
be  assured  in  those  cases  where  gold  is  objectionable. 

The  question  of  thermal  influence  under  gold  fillings  has 
claimed  much  attention  from  the  profession,  and  there  has  been  a 
large  degree  of  misconception  concerning  it.  Gold  has  been  cred- 
ited with  more  mischief  in  this  particular  than  its  merits  warrant; 
for,  while  the  material  itself  is  a  good  conductor,  it  can  be  used  in 
the  mouth  with  little  discomfort  and  little  danger,  provided  proper 
precautions  are  taken.  Gold  is  well  tolerated  even  in  large  cavi- 
ties, if  the  pulp  is  not  nearly  exposed,  or  if  there  is  not  hyper- 
sensitiveness  of  the  dentin.  In  the  former  case  the  pulp  should 
be  protected  by  an  intermediate  layer  of  cement  before  the  gold 
is  inserted,  and  in  the  latter  case  the  hypersensitiveness  should 
be  controlled  by  medication  previous  to  filling.  Probably  one  of 
the  best  agents  for  this  purpose  is  ninety-five  per  cent,  phenol. 

One  important  factor  connected  with  this  question  of  thermal 
trouble  relates  to  a  condition  apart  from  the  filling  itself.  In  the 
past,  the  profession  has  been  very  generally  advised  to  leave  in  the 
bottom  of  cavities  of  any  extent  a  portion  of  decalcified  dentin  as 
a  protection  to  the  pulp,  the  fallacy  of  which  has  already  been 
pointed  out..  Gold  has  frequently  been  severely  censured  when 
the  chief  factor  at  fault  in  the  case  has  been  the  presence  in  the 
cavity  of  a  hypersensitive  mass  of  decalcified  tissue  which  should 
have  been  removed  in  the  preparation  of  the  cavity. 

If  these  precautions  are  taken,  the  trouble  from  thermal  changes 
under  a  gold  filling  will  be  found  for  the  most  part  temporary, 


FILLING-MATERIALS  141 

and  not  of  such  serious  import  as  has  usually  been  attributed 
to  it. 

The  indications  for  or  against  the  use  of  gold  in  filling  teeth 
relate  to  conditions  most  of  which  must  be  apparent  to  every  ob- 
servant operator.  It  should  be  used  in  all  cases,  if  possible,  where 
the  greatest  utility  and  the  greatest  permanence  are  expected  of 
the  operation.  It  should  not  be  used  where  the  conditions  are 
such  that  it  is  manifestly  impossible  to  accomplish  perfect  work 
with  it.  The  control  of  the  patient,  whether  young  or  old,  is  a 
necessary  concomitant  to  the  successful  use  of  gold.  It  should 
not  be  attempted  with  a  patient  upon  whom  the  physical  or 
nervous  tax  would  be  too  great,  nor  should  it  be  employed  in  a 
tooth  the  pericemental  membrane  of  which  is  so  greatly  impaired 
as  to  revolt  seriously  against  the  impact  of  the  mallet.  In  short, 
the  best  judgment  and  the  closest  discrimination  should  be  exer- 
cised to  the  end  that  this  king  of  all  filling-materials  be  not  cru- 
cified by  the  enthusiastic  unwisdom  of  its  chief  advocates.  Since 
the  general  introduction  of  inlay  work  gold  may  be  acceptably 
used  in  this  way  in  those  extensive  restorations,  where  the  inser- 
tion of  foil  would  be  irksome,  a  subject  to  be  considered  in 
detail  later. 

Combinations  of  Gold  with  Other  Materials 

Gold-and-Platinum.— This  material  makes  a  harder  filling  and 
one  capable  of  greater  wear  than  gold  alone.  It  is  also — as 
has  been  indicated — possible  to  produce  with  it  fillings  of  varying 
degrees  of  shade  which  may  be  made  to  harmonize  agreeably  with 
the  different  types  of  patients  which  come  under  our  hands. 
These  degrees  of  shade  are  regulated  by  the  percentage  of  gold- 
and-platinum  in  the  given  product.  One  preparation  contains 
more  gold  than  platinum,  another  about  equal  parts,  while  a 
third  has  a  preponderance  of  platinum,  and  the  color  is  thereby 
affected  so  as  to  range  from  a  decidedly  yellowish  to  a  decidedly 
grayish  tinge.  This  variation  of  the  material  may  be  used  to 
striking  advantage  in  harmonizing  the  filling  with  the  features 
of  the  patient. 

The  combination  of  gold-and-platinum  should  be  employed  to  a 
greater  extent  by  the  profession  than  it  is  to-day,  for,  while  its 
manipulation  is  somewhat  more  exacting  than  that  of  gold,  its  in- 
telligent use  will  lead  to  artistic  results  not  attainable  with  gold 


142  PRINCIPLES    AND    PRACTICE    OF   FILLING    TEETH 

alone,  and  its  superior  density  adds  greater  permanence  to  the  sur- 
faces of  all  fillings  which  are  in  any  way  subject  to  attrition.  Its 
manipulation  will  be  considered  later. 

Gold-and-Tin.- — This  combination  of  materials  possesses  quali- 
ties which  should  commend  it  to  the  favorable  attention  of  the 
profession.  If  its  limitations  are  understood  and  the  cases  care- 
fully selected  for  its  use,  it  will  prove  a  source  of  great  satisfac- 
tion both  to  patient  and  practitioner;  and  it  is  therefore  worthy 
of  sufficient  merit  to  induce  every  operator  to  study  its  character- 
istics and  master  the  details  of  its  manipulation.  The  claim  has 
been  made  that  it  possesses  no  virtues  which  may  not  be  found  in 
non-cohesive  gold,  but  in  two  important  particulars  this  would 
seem  to  be  an  error.  The  tin  foil  imparts  to  the  mass  a  quality 
which  non-cohesive  gold  does  not  possess,  viz.,  a  lead-like  con- 
sistence which  makes  the  product  tougher  and  more  readily 
adapted  to  walls  of  cavities.  A  plugger-point  will  not  penetrate 
gold-and-tin  so  easily  as  it  will  a  similar  mass  of  non-cohesive 
gold;  and  another  important  item  is  the  fact  that  the  filling  will 
build  up  more  rapidly  under  the  plugger  than  will  gold  with 
equal  manipulation.  A  filling  of  gold-and-tin  may  therefore 
be  inserted  in  less  time  than  a  similarly  condensed  filling  of  gold. 
But  probably  the  most  important  difference  between  this  com- 
bination and  non-cohesive  gold  lies  in  the  fact  that  in  most 
instances,  after  a  filling  of  gold-and-tin  has  been  inserted  for  a 
time,  the  material  undergoes  a  change  which  renders  it  much 
harder  than  it  originally  was,  or  than  non-cohesive  gold  can 
possibly  be  made.  It  becomes  crystalline  in  character,  so  that 
the  filling  is  an  integral  mass,  with  little  distinction  between  the 
gold  and  the  tin.  When  it  is  first  inserted,  it  is  easily  picked 
apart;  but  after  several  years'  service  in  the  mouth  it  becomes 
almost  vitreous  in  nature,  so  that  an  excavator  when  drawn 
across  it  will  respond  with  a  metallic  vibration.  It  has  lost  its 
dead  softness  and  taken  on  a  crystalline  character  which  greatly 
increases  its  resisting  properties  and  adds  to  its  serviceability. 

Its  hmitations  consist  in  the  fact  that  it  will  discolor  in  the 
mouth,  so  that  it  cannot  be  used  in  any  position  where  it  may  be 
seen,  and  also  that  it  can  never  be  built  into  contours  or  used  in 
cavities  of  sufficiently  large  area  to  bring  any  considerable  attri- 
tion of  mastication  upon  it.  The  indications  for  its  use  relate 
principally  to  occlusal  cavities  in  molars  and  bicuspids  for  chil- 
dren, and  along  the  gingival  third  of  deep  occluso-proximal  cavities 


FILLING-MATERIALS  143 

in  molars  and  bicuspids  where  the  main  body  of  the  filhng  is  to 
be  of  gold.  It  is  especially  useful  in  this  latter  case  on  account  of 
materially  shortening  the  operation  and  avoiding  any  possibility 
of  discomfort  from  thermal  changes,  owing  to  the  reduced  conduct- 
ive properties  of  the  tin  in  the  combination.  The  rapidity 
with  which  it  may  be  inserted  renders  it  a  very  desirable  material 
in  the  mouths  of  children,  where  the  avoidance  of  the  rubber  dam 
is  an  important  consideration. 

Gold-and-tin  cannot  be  expected  to  do  the  same  length  of  serv- 
ice as  gold  in  any  position  where  it  is  subjected  to  the  constant 
attrition  of  mastication,  and  yet  many  of  these  occlusal  fillings 
which  have  been  under  observation  for  fifteen  or  more  years  give 
every  prospect  of  long-continued  usefulness — their  length  of  serv- 
ice in  most  cases  being  out  of  all  proportion  to  the  limited  time 
necessary  for  their  insertion. 

Amalgam 

This  material  has  been  at  once  the  refuge  and  despair  of  the 
dental  profession.  It  has  saved  many  teeth  that  would  have 
been  lost  without  it,  and  yet  in  its  intrinsic  properties  as  a  mate- 
rial it  cannot  be  compared  with  gold  either  in  the  form  of  foil  or 
inlays.  Within  the  last  decade  the  manufacturers,  stimulated 
largely  by  the  researches  of  the  late  Dr.  G.  V.  Black,  have  given 
us  a  better  and  more  reliable  product,  and  yet  to  say  the  best  of 
amalgam  it  cannot  be  claimed  that  it  is  uniform  in  its  behavior 
even  under  uniform  methods  of  manipulation. 

The  chief  faults  with  amalgam,  as  presented  to  us  in  the  past, 
have  exhibited  themselves  in  a  tendency  to  compress  under  the 
impact  of  mastication,  so  as  to  be  drawn  away  from  the  cavity- 
walls,  but  more  particularly  in  a  tendency  to  so  change  form, 
even  after  crystallization  has  taken  place  and  where  no  undue 
pressure  is  exerted,  as  to  produce  a  serious  leak  between  the  filling 
and  the  wall  of  the  cavity.  This  is  frequently  exhibited  in  a  de- 
cided crack  along  the  cavity-margins,  easily  visible  to  the  naked 
eye,  and  capable  of  allowing  the  ingress  of  deleterious  agents  cal- 
culated to  bring  about  recurrence  of  decay  around  the  filling. 
These  cracks  do  not  need  to  be  large  enough  to  be  seen  in  order  to 
invite  mischief,  and  very  many  teeth  have  been  lost  in  the  past  as 
the  result  of  this  one  characteristic  of  amalgam.  The  color  of 
amalgam  is  also  against  it,  but  particularly  the  fact  that  much  of 


144  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

the  amalgam  used  by  the  profession  has  so  changed  color  after 
its  insertion  in  the  mouth  as  to  render  it  most  unsightly. 

These  various  faults  of  amalgam  have  claimed  the  attention  of 
the  ^profession  for  years,  but  no  one  would  seem  to  have  overcome 
them  in  any  encouraging  degree  till  the  investigations  of  Dr. 
Black.  After  the  most  painstaking  study  of  the  physical  charac- 
ter of  the  various  alloys,  he  was  finally  enabled  to  produce  one 
which  would  neither  shrink  nor  expand,  and  which  would  sustain 
sufiicient  stress  to  make  it  reasonably  serviceable  in  the  mouth. 
But  the  conditions  surrounding  the  manufacture  and  manipu- 
lation of  such  an  alloy  are  so  intricate  and  so  exacting,  and  the 
ingredients  so  sensitive  to  the  slightest  variation  in  temperature  or 
in  treatment,  that  to  produce  a  uniform  product  from  one  time  to 
another  would  seem  to  be  well-nigh  beyond  the  possibility  of 
human  attainment.  Manufacturers  find  that  an  ingot  melted 
from  a  given  formula  may  give  a  certain  result,  while  another  ingot 
from  the  same  formula,  and  apparently  treated  in  the  same  way, 
will  show  a  variation  in  the  result.  The  closest  attention  to  the 
minutiae  is,  therefore,  necessary  all  along  the  line,  from  the  re- 
fining of  the  original  metals  down  to  the  filing  and  annealing  of 
the  finished  product.  Even  then  no  one  batch  of  alloy  should 
ever  be  sent  out  short  of  a  final  test  of  the  amalgam  made  from  it 
by  the  most  delicate  machinery;  and,  in  passing,  it  may  be  stated 
that  when  these  tests  are  made  they  frequently  prove  a  source  of 
discouragement  to  the  conscientious  manufacturer.  Discrep- 
ancies arise  at  every  hand  where,  apparently,  the  greatest  care 
had  been  taken  with  the  preparation,  and  the  more  this  amalgam 
question  is  studied,  the  more  it  would  seem  to  be  hedged  about  by 
hmitations  so  great  as  to  be  disheartening  in  view  of  the  immense 
amount  of  the  material  being  used  at  the  present  day.  It  would 
probably  be  better  for  the  profession  and  the  public  if  much  of  the 
energy  which  is  now  being  expended  on  amalgam  were  diverted  to 
other  materials  which  are  capable  of  more  definite  and  uniform 
results. 

And  yet  amalgam  under  existing  conditions  cannot  well  be  ex- 
cluded from  our  present  list  of  filling-materials.  It  has  been  too 
useful  for  certain  purposes,  even  with  its  limitations,  to  be  entirely 
discarded  and  the  investigations  of  many  men  since  Dr.  Black's 
experiments  promise  to  give  us  a  better  product  in  the  future. 
Its  chief  utility  relates  to  the  building  up  of  teeth  so  badly  broken 
down  or  so  remotely  situated  in  the  mouth  as  to  render  the 


FILLING-MATERIALS  145 

use  of  gold  too  exacting.  Employed  with  discriminating  care, 
amalgam  may,  under  these  conditions,  serve  a  useful  purpose  but 
it  can  never  hope  to  attain  to  the  same  degree  of  excellence  as  a 
saver  of  teeth  that  has  long  since  been  established  by  gold. 

Tin 

The  statement  has  often  been  made  that  this  material  does  not 
claim  from  the  profession  the  attention  which  its  virtues  merit, 
and  this  is  probably  true,  though  it  would  seem  that  the  combina- 
tion of  gold-and-tin  possesses  all  of  the  advantages  of  tin  alone, 
together  with  the  added  virtue  of  being  better  able  to  resist  wear 
on  account  of  its  greater  hardness. 

Tin  may  be  used  in  one  of  two  forms — that  of  foil,  or  in  the 
form  of  shavings  cut  from  block  tin.  The  former  is  perfectly 
non-cohesive  while  the  latter,  if  freshlj^  cut,  is  said  to  possess  cohe- 
sive properties,  though  tin  cannot  be  built  into  contours  with  any 
assurance  of  permanence  on  account  of  its  softness.  The  indica- 
tions for  the  use  of  tin  are  practically  the  same  as  those  suggested 
for  gold-and-tin — it  being  especially  useful  in  any  position  where 
it  is  surrounded  by  four  walls  and  is  not  subjected  to  wear.  It  is 
readily  adapted  to  the  cavity,  will  retain  its  form  perfectly,  except 
under  pressure,  and  it  is  a  poor  conductor.  This  suggests  that  tin 
may  serviceably  be  employed  in  simple  cavities  in  all  posterior 
teeth,  such  as  buccal  or  lingual  cavities  of  limited  area,  or  in  proxi- 
mal cavities  which  do  not  involve  the  occlusal  surface. 

Cements 

There  are  three  main  varieties  of  cement — the  oxychlorid  of 
zinc,  the  oxyphosphate  of  zinc,  and  the  oxyphosphate  of  copper. 
The  oxychlorid  of  zinc  is  indicated  in  pulpless  teeth,  for  filling  the 
pulp-chamber  after  the  canals  have  been  previously  filled  with 
gutta-percha,  and  also  to  form  a  lining  to  the  cavity  under  the  fill- 
ing proper.  It  is  seldom  indicated  in  teeth  with  living  pulps,  par- 
ticularly if  there  is  a  near  approach  to  the  pulp  or  if  there  is  much 
hypersensitiveness,  on  account  of  its  strong  irritating  properties. 
Neither  can  it  be  relied  on  for  reasonable  service  in  any  position 
where  it  is  subjected  to  the  fluids  of  the  mouth,  from  the  fact  that 
it  is  so  readily  dissolved — this  being  especially  true  of  proximal 
cavities  at  the  gingival  margin. 

The  oxyphosphate  of  zinc  is  arx  excellent  agent  as  an  inter- 
mediate under  metal  fillings  in  cases  where  there  is  a  near  ap- 

10 


146  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

proach  to  the  pulp — it  being  less  of  an  irritant  than  the  oxy  chlorid-^ 
and  also  for  a  temporary  filling-material  in  the  management  of 
teeth  which  for  any  reason  may  not  be  in  a  condition  for  a  perma- 
nent operation.  Its  chief  limitation  consists  in  a  tendency  to  dis- 
solve under  the  fluids  of  the  mouth,  though  it  is  not  so  subject  to 
this  fault  as  is  the  oxychlorid,  and  there  is  a  considerable  variation 
in  its  behavior  in  different  mouths.  In  some  instances  it  seems  to 
wear  well  for  years,  particularly  if  the  material  used  is  of  superior 
quality  and  it  receives  proper  manipulation,  but  at  best  it  may  be 
accounted  only  a  temporary  expedient  and  should  not  be  relied  on 
for  permanent  service.  Its  chief  use  in  operative  dentistry  to-day 
is  the  purpose  of  cementing  inlays  to  place. 

The  oxyphosphate  of  copper,  introduced  by  Dr.  Ames,  of  Chi- 
cago, is  also  somewhat  soluble  in  the  mouth,  particularly  in  vulner- 
able positions;  and  the  fact  that  it  is  intensely  black  in  color  limits 
its  use  to  positions  not  exposed  to  view.  It  is  especially  indicated 
in  remote  cavities  in  the  necks  of  teeth  occasioned  by  a  recession 
of  the  gum,  where  the  cavity  is  so  ill  defined  as  to  make  the  use  of 
gutta-percha  or  amalgam  difficult.  It  may  be  made  to  adhere  to 
the  surface  of  a  cavity  very  tenaciously,  so  that  little  undercutting 
is  necessary,  and  it  will  prove  an  excellent  expedient  in  that  par- 
ticular class  of  cases  for  which  no  other  kind  of  filling  seems  suited. 

Gutta-Percha 

This  is  a  material  which  deserves  more  attention  from  the  pro- 
fession than  it  has  received.  In  the  particular  field  for  which  it  is 
best  suited  it  has  no  equal,  and  its  uses  are  vtoed  and  unique  in 
the  saving  of  teeth.  Its  chief  limitation  lies  in  the  fact  that  it  is  not 
sufficiently  hard  to  withstand  attrition,  but  placed  in  positions 
secure  from  wear  it  gives  most  excellent  results.  It  is  not  dissolved 
by  the  fluids  of  the  mouth,  and  it  is  one  of  the  best  of  non-conduc- 
tors. As  a  temporary  sealing  agent  in  the  treatment  of  teeth  it  is, 
without  question,  the  best  material  we  possess.  It  is  especially  in- 
dicated for  the  filling  of  pulp-canals,  being  non-irritant,  imper- 
vious to  moisture,  and  readily  molded  to  fit  any  inequality  in  the 
canal.  It  is  also  very  valuable  as  a  temporary  filling-material  in 
connection  with  oxyphosphate  of  zinc  for  proximal  cavities,  the 
gutta-percha  being  used  in  the  gingival  third  of  the  cavity  and  the 
filling  completed  with  cement.  •  Gutta-percha  will  not  dissolve  out 
under  these  conditions,  as  will  most  of  the  cements;  nor  will  the 


FILLING-MATERIALS  147 

latter  wear  away  so  rapidly  under  attrition  as  will  gutta-percha,  so 
that  by  combining  the  two  materials  in  this  manner  in  the  same 
cavity  the  operator  gains  the  advantage  of  more  adequate  pro- 
tection to  the  gingival  margin  and  a  better  wearing  service  on  the 
occlusal  portion  of  the  filling. 

The  Silicate  Cements 

During  recent  years  these  materials  have  taken  an  increasingly 
strong  hold  on  the  profession  and  the  present  indications  would 
seem  to  encourage  us  in  the  belief  that  they  are  to  form  an  impor- 
tant adjunct  to  our  means  of  filling  teeth.  More  and  more  the 
necessity  is  forced  upon  us  to  seek  a  material  for  work  in  the 
anterior  part  of  the  mouth  which  will  not  be  conspicuous  in 
appearance.  The  silicates  are  more  satisfactory  in  this  respect 
than  anything  yet  introduced,  even  porcelain  itself  not  being 
comparable  with  them.  With  porcelain  there  is  ordinarily  a 
line  which  shows  sooner  or  later  between  the  porcelain  and  the 
tooth,  while  the  silicates  may  be  so  perfectly  blended  with  the 
enamel  margin  as  to  be  indistinguishable  from  it.  It  is  possible 
in  many  instances  to  so  match  the  shade  of  the  tooth  as  to  defy 
detection  at  conversational  distance  from  the  patient. 

The  limitations  of  the  silicates  relate  to  the  friable  nature  of 
the  material,  which  renders  it  unstable  under  ordinary  stress,  and 
to  the  fact  that  in  some  instances  it  appears  to  shrink  and  dis- 
integrate in  a  way  to  make  it  a  temporary  filling-material.  In 
some  cases  this  result  seems  to  be  due  to  the  peculiar  condition  of 
the  fluids  of  the  mouth  in  certain  individuals,  while  in  others  it  is 
undoubtedly  due  to  faulty  methods  of  manipulation.  The 
material  has  not  been  sufficiently  long  in  use  to  thoroughly 
standardize  its  management. 

The  chief  indications  for  its  use  are  in  all  cavities  exposed  to 
view  but  not  to  stress,  and  as  a  labial  or  buccal  face  to  large  res- 
torations with  gold  inlays  to  hide  the  gold.  They  are  especially 
acceptable  in  cavities  in  the  gingival  region  of  labial  or  buccal 
surfaces  which  are  exposed,  and  though  they  sometimes  prove 
temporary  in  nature  yet  their  renewal  is  not  a  serious  matter,  and 
many  patients  will  prefer  to  have  them  inserted  on  account  of 
their  superior  appearance  even  though  they  must  be  occasionally 
renewed.  The  hope  is  hereby  expressed  that  we  shall  in  the 
future  have  an  improved  product,  and  shall  learn  more  about  its 


148  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

proper  management,  so  that  the  virtue  which  the  material  un- 
questionably possesses  in  appearance  may  be  made  more  widely 
applicable. 

Inlays 

The  constantly  increasing  importance  of  inlays  as  a  means 
of  saving  the  natural  teeth  from  the  ravages  of  decay  makes  it 
imperative  for  the  operator  who  would  do  the  best  service  for 
his  patient  to  become  thoroughly  familiar  with  this  work. 
Porcelain  inlays  are  not  nearly  so  much  in  use  as  formerly,  and 
yet  there  are  certain  conditions  which  are  not  so  perfectly  met 
by  any  other  means  as  by  the  porcelain  inlay  and  therefore 
every  operator  should  know  how  to  make  them.  It  is  true  that 
in  many  of  the  contour  restorations  in  anterior  teeth  the  porce- 
lain inlay  has  been  largely  displaced  by  a  combination  of  the 
gold  inlay  with  the  silicate  cements,  the  latter  being  used  on  the 
exposed  surface  and  the  gold  employed  for  the  bulk  of  the  filling 
where  stress  is  brought  to  bear.  These  operations  give  promise 
of  good  service  but  the  method  has  not  been  used  sufficiently 
extensively  or  long  to  enable  us  to  form  a  reliable  opinion  as  to 
the  probable  permanence  of  the  silicate  when  employed  in  this 
way.  We  know  that  porcelain  is  hard  enough  to  withstand 
much  wear,  but  we  also  know  that  its  friability  renders  it  vul- 
nerable along  margins,  and  where  there  is  little  bulk  to  support 
it.  The  fact  is  that  we  have  as  yet  no  absolutely  reliable  filling- 
material  for  these  anterior  restorations  which  will  at  the  same 
time  be  strong  and  satisfactory  in  appearance,  and  it  is  sometimes 
a  nice  choice  between  the  combination  of  gold  and  silicate,  and 
the  porcelain  inlay.  To  be  well  equipped  an  operator  should 
know  how  to  insert  either. 

As  for  the  gold  inlay,  the  impetus  given  this  work  by  the  intro- 
duction of  the  cast  gold  inlay  by  Dr.  W.  H.  Taggart  has  led  to  a 
very  extended  use  of  the  method  in  all  parts  of  the  world,  till 
now  it  has  assumed  a  place  in  the  practice  of  dentistry  second  to 
no  other.  By  its  means  teeth  may  be  saved  serviceably  and 
without  undue  nervous  tension  on  the  patient  or  operator,  even 
where  they  are  so  extensively  involved  that  otherwise  a  crown 
would  be  necessary.  This  work  is  no  longer  in  its  experimental 
stage  but  has  become  a  standard  and  accepted  system  of  prac- 
tice, and  no  operator  is  equipped  to  render  his  patient  the  best 
service  who  has  not  mastered  its  every  detail. 


FILLING-MATERIALS  149 

The  cases  indicated  for  its  use  are  in  all  cavities  of  sufficient 
size  to  make  the  insertion  of  gold  foil  too  much  of  a  nervous  tax 
on  the  patient,  or  in  all  cases  where  a  better  technique  can  be 
obtained  with  it  than  with  foil.  The  fact  still  stands  that  there 
has  never  yet  been  a  filling-material  introduced  which  for  per- 
manence will  compare  with  the  well-adapted,  well-condensed, 
and  well-finished  gold  foil  filling,  where  the  gold  is  so  perfectly 
adapted  to  the  walls  of  the  cavity  as  to  hermeticallj'^  seal  it, 
and  where  the  density  of  the  filling  is  so  great  that  it  will  withstand 
the  full  stress  of  mastication.  But  in  the  manipulation  of  gold 
the  exactions  are  so  great  to  secure  this  perfect  result  that  it  is 
not  always  possible  of  attainment  in  many  of  the  cases  which  we 
encounter  in  practice,  and  in  these  cases  better  results  may  be 
secured  with  inlays.  The  rule  should  prevail  that  by  whatever 
method  we  can  do  the  most  serviceable  work,  that  method  should 
be  used.  We  should  not  be  wedded  to  a  prejudiced  following  of 
any  one  method  but  should  be  prepared  to  take  advantage  of  the 
best  there  is  in  all  methods  and  turn  this  to  the  advantage  of 
our  patient. 


CHAPTER  VII 
GOLD 

Cohesive  and  Non-Cohesive  Gold 

All  gold  for  filling  teeth  should  be  as  pure  as  it  can  be  made. 
The  distinction  between  cohesive  and  non-cohesive  gold  does  not 
so  much  relate  to  its  purity  as  to  the  condition  of  its  surface.  If 
two  layers  of  gold  foil  which  is  perfectly  pure  and  perfectly  clean 
upon  its  surface  be  brought  into  intimate  contact  at  ordinary 
temperatures,  they  will  cohere.  In  other  words,  they  will  weld 
cold.  Two  pieces  of  gold  in  this  condition  cannot  be  rubbed  to- 
gether without  sticking.  This  is  an  inherent  quality  of  gold  when 
pure  and  clean,  and  it  is  gold  in  this  state  which  is  termed  cohesive 
gold. 

If  pure  gold  foil  be  exposed  to  the  atmosphere  for  any  length  of 
time,  or  is  brought  in  contact  with  certain  gases,  it  gathers  upon 
its  surface  an  imperceptible  film,  which,  while  not  affecting  the 
purity  of  the  substance  itself,  interferes  with  its  cohesion.  Two 
layers  of  foil  in  this  condition  may  be  rubbed  together  without 
adhering.     This  is  called  non-cohesive  gold. 

In  accordance  with  this,  it  might  naturally  be  assumed  that, 
given  a  piece  of  pure  and  clean  gold  foil,  it  could  be  made  cohe- 
sive or  non-cohesive  at  will,  and  this  is  in  strict  agreement  with 
fact.  A  pellet  of  cohesive  gold  may  be  made  non-cohesive  by 
exposing  it  to  the  influence  of  ammonia  gas,  and  this  pellet,  thus 
rendered  non-cohesive,  may  in  turn  be  made  cohesive  by  driving 
off  the  gas  with  heat.  It  is  on  this  hypothesis  that  we  anneal 
our  gold  for  filling  teeth.  But  there  are  some  gases  which,  if  al- 
lowed to  come  in  contact  with  the  surface  of  gold  foil,  apparently 
cannot  be  driven  off  by  heat,  and  thus  render  the  gold  perma- 
nently non-cohesive.  Exposure  to  the  atmosphere  under  certain 
conditions  for  an  extended  period  seems  to  have  the  same  effect, 
so  that  operators  who  wish  their  gold  to  work  uniformly  fresh  and 
cohesive  should  keep  it  protected  from  the  atmosphere. 

The  difference  in  behavior  of  cohesive  and  non-cohesive  gold 
under  the  plugger  is  readily  suggested  by  the  characteristics  of  the 

150 


GOLD  151 

two  materials.  From  the  fact  that  with  non-cohesive  gold  one 
pellet  may  be  forced  across  another  without  adhering  to  it  we  are 
able  conveniently  to  carry  such  gold  into  corners  of  cavities  diffi- 
cult of  access  and  secure  ready  adaptation  to  walls,  but  the 
absence  of  cohesion  between  the  layers  of  foil  limits  us  in  any 
attempt  to  build  it  into  contours.  With  cohesive  gold  we  have 
the  advantage  of  giving  any  desired  form  to  the  filling  and  ob- 
taining increased  strength  to  the  mass,  with  the  limitation  of 
greater  difficulty  in  securing  adaptation  to  points  not  easy  of 
access.  This  does  not  imply  that  adequate  adaptation  cannot 
be  gained  with  cohesive  gold.  Cohesive  gold  may  be  adapted  to 
the  wall  of  a  cavity  with  as  great  a  degree  of  perfection  as  can 
non-cohesive,  but  the  method  of  manipulation  is  more  exacting 
and  less  rapid. 

From  the  fact  that  a  pellet  of  cohesive  gold  will  immediately 
stick  to  gold  which  has  already  been  placed  in  the  cavity,  care 
must  be  exercised  in  adding  each  fresh  pellet  to  locate  it  in  pre- 
cisely the  position  where  it  is  intended  to  condense  it.  If  it  is 
allowed  to  come  in  contact  with  any  part  of  the  surface  remote 
from  the  point  indicated,  it  cannot  be  forced  across  the  surface  to 
the  proper  position  on  account  of  its  cohesion.  With  non- 
cohesive  gold  there  is  more  latitude  in  this  particular,  but,  prop- 
erly placed  and  thoroughly  condensed,  cohesive  gold  may  be 
made  to  seal  a  cavity  perfectly. 

Annealing  Gold 

Much  of  the  difficulty  experienced  by  operators  in  the  insertion 
of  gold  is  due  to  faulty  methods  of  annealing;  and,  even  among 
operators  who  are  sufficiently  skilled  to  obtain  good  results  by  the 
ordinary  methods,  there  is  much  to  be  gained  by  adopting  the 
best  methods  in  this  important  particular.  The  great  majority 
of  operators  are  in  the  habit  of  annealing  their  gold  by  passing 
it  through  the  flame  of  a  spirit  lamp  or  a  Bunsen  burner — 
a  method  which  has  serious  objections.  In  either  instance  we  are 
never  certain  of  always  having  a  pure  flame,  and  if  we  do  not 
have  a  pure  flame  we  jeopardize  the  working  quality  of  the  gold. 
An  alcohol  flame  is  seldom  uniform  in  its  character,  from  the 
fact  that  it  is  so  appreciably  affected  by  atmospheric  changes. 
An  undue  humidity  in  the  operating  room  will  result  in  a  vitiated 
flame,  which  shows  itself  in  a  yellowish  tinge.     The  presence  of 


152  PEINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

moisture  in  the  air  always  affects  this  flame,  owing  to  the  great 
affinity  which  alcohol  has  for  water. 

The  gas  flame  from  a  Bunsen  burner  is  more  reliable  than  the 
alcohol  flame,  but  it  is  not  without  its  limitations.  The  operator 
is  always  dependent  on  the  gas  company  to  furnish  him  a  pure 
quahty  of  gas,  and  he  must  watch  the  burner  to  keep  it  in  perfect 
working  order  if  he  expects  a  uniform  flame.  Even  at  the  best, 
it  is  doubtful  if  gold  coming  in  contact  with  any  flame  is  not  in 
more  or  less  danger  of  contamination. 

Then  the  manner  of  annealing  followed  by  many  operators  is 
calculated  to  give  unequal  results,  even  with  a  pure  flame.  If 
a  pellet  of  gold  be  picked  up  by  the  pliers  and  carried  through  the 
flame  and  then  to  the  filling,  as  is  so  frequently  done,  nearly  one- 
half  of  the  pellet  is  imperfectly  annealed.  The  portion  of  gold 
grasped  by  the  pliers  is  not  annealed  at  all,  and  for  some  distance 
from  the  plier-points  the  gold  is  kept  sufficiently  cooled  by  the 
points  to  prevent  perfect  annealing.  This  accounts  for  much  of 
the  pitting  on  the  surfaces  of  some  gold  fillings.  A  certain  por- 
tion of  every  pellet  is  left  non-cohesive,  and  when  wear  is  brought 
upon  the  filling  these  little  particles  which  were  grasped  by  the 
plier-points  flake  off,  leaving  an  imperfect  surface.  The  operator 
does  not  notice  this  defect  while  building  up  the  filling  because  of 
the  fact  that  the  end  of  the  pellet  most  remote  from  the  pliers  is 
well  annealed,  and  this,  coming  in  contact  with  the  gold  in  the 
cavity,  adheres  perfectly,  and  the  whole  pellet  seems  to  mallet 
down  to  place  in  good  condition.  It  is  only  when  subsequent 
attrition  on  the  filling  discloses  the  flaked  surface  that  the 
operator  realizes  there  is  something  wrong  with  the  density  of  his 
gold;  and  even  then  he  is  quite  likely  to  attribute  it  to  some  in- 
herent defect  in  the  gold  rather  than  to  faulty  methods  on  his  part. 
This  plan  of  annealing  also  occasionally  leads  to  another  detri- 
mental effect.  The  operator,  in  observing  the  pellet  in  the  flame, 
notes  that  it  is  dark  in  color  for  more  than  half  its  length  from  the 
plier-points,  and  attempts  to  get  a  uniform  heating  by  holding 
it  longer  in  the  flame.  This  results  in  the  overheating  of  the 
pellet  at  the  end  most  remote  from  the  pliers,  and  the  fusing 
together  of  the  layers  of  foil  at  that  point  so  as  to  present  a 
harsh,  unyielding  mass,  with  which  it  is  impossible  to  do  uniform 
work.  If  an  operator  must  employ  the  flame  for  annealing  he 
would  better  use  the  smallest  pliers  obtainable,  and  grasp  the 
minute  corner  of  one  end  of  the  pellet  and  pass  it  carefully  through 


GOLD  153 

the  flame,  or  near  the  flame,  till  the  other  end  reddens.  Then, 
dropping  the  pellet  in  the  gold  drawer,  he  should  pick  it  up  again 
at  the  annealed  end  and  gently  heat  the  other  one.  In  this  way 
both  ends  are  annealed ;  but  even  then  there  is  a  lack  of  uniformity 
in  such  a  method,  and  it  also  requires  unnecessary  time  and  undue 
manipulation  of  the  pellet  before  it  reaches  the  cavity.  A  pellet 
should  be  handled  as  little  as  need  be  from  the  time  it  leaves 
the  gold-beater  till  it  is  placed  in  position  in  the  tooth. 

Another  method  employed  by  some  operators  to  obviate  the 
difficulties  just  indicated  is  to  roll  their  foil  into  a  rope  of  suitable 
size,  and  then  anneal  the  entire  rope,  cutting  it  into  pellets  subse- 
quently. An  objection  to  this  is  found  in  the  fact  that  with  a 
rope  of  annealed  gold  the  impact  of  the  scissors  in  cutting  the 
pellets  compresses  the  rope  so  that  there  is  a  line  of  condensed 
gold  across  each  end  of  each  pellet  before  it  is  placed  in  the  cavity. 
This  may  appear  a  trivial  consideration,  and  yet  it  is  attention  to 
the  minutiae  which  goes  to  make  up  the  most  perfect  result  in  the 
insertion  of  gold.  A  pellet  condensed  at  either  end  in  this  way 
is  not  so  obedient  to  the  plugger,  nor  can  it  be  so  accurately 
manipulated  in  the  performance  of  delicate  work  as  can  a  uniform 
pellet. 

The  plan  of  some  operators  whereby  the  plugger-point  is  used 
to  pick  the  gold  from  the  drawer  and  carry  it  to  the  flame  and 
then  to  the  cavity,  is  objectionable  in  several  particulars.  Unless 
the  point  is  heated  sufficiently  to  ruin  its  quality  as  a  plugger,  the 
gold  is  never  perfectly  annealed  in  the  region  of  the  point.  If  it 
is  annealed  at  all  adequately,  the  point  is  made  so  hot  as  to  be 
painful  to  the  patient  on  application  to  the  tooth,  and  the  prod- 
ucts of  repeated  oxidation  at  the  end  of  the  point  are  continually 
being  incorporated  into  the  structure  of  the  filling,  which,  at  best, 
cannot  result  to  its  benefit.  There  is  also  a  lack  of  uniformity 
in  the  degree  of  annealing  throughout  the  pellet,  the  ends  being 
invariably  heated  higher  than  the  part  touched  by  the  plugger- 
point.  The  same  condition  exists,  though  in  a  modified  degree, 
when  a  smaller  instrument  is  used  for  picking  up  the  gold  in  lieu  of 
a  plugger,  as  practised  by  some  operators.  Another  minor  objec- 
tion relates  to  the  fact  that  when  a  pellet  is  annealed  in  this  way  it 
has  a  tendency  to  slightly  change  its  form  under  the  flame,  so  as  to 
drop  from  the  plugger  or  annealing  instrument  and  fall  into  the 
flame. 

In  view  of  these  considerations,  it  would  seem  desirable  for  the 


154 


PRINCIPLES    AND    PRACTICE    OF    FILLING   TEETH 


profession  to  adopt  a  different  method  of  annealing  gold  to  obtain 
the  best  results.  The  problem  to  be  solved  is  simply  to  heat  the 
gold  sufficiently  to  effectively  drive  off  all  gases  from  its  surface 
without  the  possibility  of  concurrent  contamination,  and  with 
absolute  uniformity  of  annealing  throughout  the  mass.  Various 
methods  have  been  devised  for  this  purpose,  the  one  most  em- 
ployed in  the  past  being  to  place  the  gold  on  a  mica  or  metal 
tray  over  the  spirit  lamp,  and  allow  the  heat  thus  generated  to 
gradually  accomplish  the  purpose;  but  the  most  perfect  method 


Fig.  93. 


yet  suggested  is  through  the  medium  of  the  electric  gold  annealer 
devised  by  Dr.  L.  E.  Custer,  of  Dayton,  Ohio  (Fig.  93). "  With 
this  appliance  complete  uniformity  of  result  is  obtained  in  the 
most  convenient  and  ready  manner,  and  with  no  liability  of 
contamination.  Even  to  operators  who  have  been  accomplishing 
apparently  satisfactory  results  by  other  means,  this  appliance 
will  soon  reveal  a  working  quaHty  to  the  gold  which  seems  im- 
possible of  attainment  in  any  other  way,  and  it  is  confidently 
believed  that  its  general  adoption  by  the  profession  would  disarm 
much  of  the  criticism  which  is  occasionally  waged  against  the 
manufacturers  of  gold  on  the  plea  of  lack  of  uniformity  in  prepa- 
ration. The  only  procedure  necessary  is  to  place  the  pellets 
in  convenient  arrangement  on  the  annealer  and  turn  on  the 
current,  which  may  be  left  running  to  the  end  of  the  operation. 
No  matter  how  long  the  current  is  on,  there  is  no  overheating 
of  the  gold.  It  simply  anneals  perfectly,  without  ever  fusing 
any  of  the  layers  of  the  pellets  together. 

A  most  satisfactory  manner  of  treating  gold  from  the  time  it 
reaches  our  hands  till  it  is  carried  to  the  tooth  is  to  first  subject  it 


GOLD 


155 


to  the  influence  of  ammonia  gas  by  placing  in  a  small  porcelain 
receptacle  a  pledget  of  cotton  saturated  with  aqua  ammonia,  and 
setting  this  in  the  same  drawer  with  the  gold,  leaving  the  box  or 
bottle  containing  the  pellets  open,  so  that  the  gas  may  readily 
act  upon  them.     The  pellets  are  thus  rendered  uniformly  soft. 


Fig.  94. 

velvety,  and  manageable.  They  are  absolutely  non-cohesive. 
They  may  be  shaken  or  rubbed  together  ad  libitum  without  one 
pellet,  even  in  the  slightest  degree,  adhering  to  another.  When 
the  filling  is  to  be  made  they  should  be  transferred  to  the  annealer 
and  the  current  turned  on,  the  result  of  which  will  furnish  a 
series  of  pellets  each  in  its  behavior  precisely  like  its  fellow. 


156  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

Gold  treated  in  this  way  has  a  beautifully  soft  working  quality, 
devoid  of  harshness,  but  capable  of  perfect  cohesion  and  density 
under  the  impact  of  the  plugger. 

With  gold  prepared  according  to  these  details,  and  with  the 
characteristics  of  its  manipulation  perfectly  understood,  it  is 
nearly  or  quite  as  easy  of  introduction  into  a  cavity  as  any  of  the 
other  filling-materials,  the  chief  distinction  being  the  greater 
length  of  time  necessary  to  insert  it.  It  must  be  built  up  piece 
by  piece,  while  most  of  the  other  materials  may  be  added  in 
masses  of  greater  bulk. 

For  those  practitioners  who  are  not  convenient  to  the  electric 
current,  an  annealer  has  been  devised  by  Dr.  J.  B.  Vernon  which 
may  be  used  with  either  gas  or  alcohol  (Fig.  94) .  A  convex  disk 
is  placed  under  the  receiving  tray  and  left  open  in  the  center  in 
such  a  way  that  the  flame  passing  through  the  aperture  distributes 
the  heat  rapidly  over  the  entire  area  of  the  tray.  The  degree  of 
heat  may  be  regulated  not  only  by  the  size  of  the  flame,  but  by  the 
adjustable  nature  of  the  frame,  which  admits  of  the  tray  being 
raised  or  lowered  at  will.  This  is  a  very  simple  and  effective 
annealer  and  one  that  may  be  made  available  in  any  office. 

It  would  seem  that  either  of  these  annealers  was  greatly  to  be 
preferred  to  the  method  so  commonly  in  vogue  of  passing  the  gold 
through  the  flame,  and  a  careful  consideration  of  this  entire  sub- 
ject of  the  proper  preparation  of  our  gold  for  filling  teeth  is  hereby 
strongly  commended  to  the  profession.  Gold  has  almost  invari- 
ably been  credited  with  the  advantage  of  having  claimed  a  more 
serious  study  in  its  management  and  a  greater  care  in  its  manipu- 
lation than  any  other  filling-material  we  possess,  and  yet  in 
this  one  particular  it  would  sometimes  appear  as  if  it  had  been 
strangely  misunderstood  in  its  characteristics  or  ignored  in  its 
chief  requirements. 

Different  Forms  of  Gold 

The  form  in  which  gold  is  used  in  filling  teeth  is  largely  one  of 
individual  preference,  whether  in  ropes,  pellets,  cylinders,  or 
strips.  Possibly  the  best  results  are  obtained  by  a  convenient 
arrangement  of  the  different  forms  in  the  same  cavity,  such,  for 
instance,  as  starting  the  filling  with  a  rope  of  non-cohesive  gold 
of  suitable  size  and  building  the  main  body  of  the  filling  with 
pellets  or  cylinders  annealed,  followed  by  strips  of  heavy  gold 
upon  the  surface.     Some  operators  are  in  the  habit  of  twisting 


GOLD  ] o7 

thoir  foil  into  ropes,  and  cutting  these  into  pellets  for  general  use. 
Oth(!rs,  whose  methods  of  operating  are  highly  individualized, 
cut  th(!  foil  into  strips  and  roll  these  into  cylinders  of  varying 
sizes  for  the  special  case  in  hand.  One  advantage  of  this  method 
is  that  the  layers  of  foil  constituting  the  cylinder  are  arranged  in  a 
regular  series,  one  upon  the  other,  and  are  therefore  capah)le  of 
a  more  even  placement  in  the  filling  than  when  the  pellets  are  cut 
from  a  twisted  rope.  This  even  arrangement  of  the  layers  of  foil 
in  building  a  filling  is  an  item  of  some  importance  in  its  relation  to 
the  strength  of  the  filling  and  its  uniform  density,  but  the  element 
of  time  in  the  preparation  of  these  cylinders  must  also  be  acknowl- 
edged as  a  consideration  with  the  busy  practitioner.  The  pre- 
pared pellets  or  cylinders  of  graded  sizes  and  lengths,  as  they 
come  to  us  from  the  manufacturers,  would  seem  to  furnish  a  most 
convenient  form  for  the  bulk  of  our  work,  and  these,  supple- 
mented on  the  surface  in  cases  calling  for  special  density  with 
strips  cut  from  Nos.  30,  60,  or  120  gold,  are  capable  of  producing 
a  uniformly  good  result.  For  the  rapid-acting  mallet,  in  cases 
where  it  may  not  seem  desirable  to  use  the  heavier  foils,  strips  can 
be  prepared  by  folding  the  lighter  foils  and  cutting  them  into 
suitable  widths.  For  instance,  a  sheet  of  No.  4  foil  may  be 
folded  three  times,  which  makes  four  layers  of  foil.  This  fold  is 
then  cut  into  strips  of  from  two  to  three  millimeters  in  width, 
making  a  very  convenient  preparation  for  the  rapid  mallet,  tack- 
ing one  end  on  the  filling  and  folding  it  back  and  forth  across  the 
surface  as  it  is  being  condensed. 

For  those  operators  who  do  not  use  the  rapid  mallet  and  who 
find  the  heavier  golds  inconvenient  or  difficult  of  manipulation 
for  surface  work,  the  following  method  of  preparing  the  gold  is 
strongly  advised.  The  folds  just  mentioned  do  not  contain  a  suf- 
ficient number  of  layers  of  foil  to  build  up  with  any  rapidity  under 
the  slower  mallets  such  as  the  hand  mallet  or  the  automatic,  Vjut- 
the  order  of  arrangement  of  the  layers  is  good  and  should  be  pre- 
served. To  do  this  take  a  whole  sheet  of  No.  4  foil  and  fold  it 
once,  having  the  margins  even  and  the  one  layer  pressed  flat  on 
the  other.  Then  fold  again  in  precisely  the  same  way,  pressing 
flat  and  even,  and  continue  the  folding  till  the  width  of  the  result- 
ing ribbon  is  about  five  or  six  millimeters,  or  a  trifle  less  than  a 
quarter  of  an  inch.  This  flat  ribbon  may  then  be  cut  into  strips 
from  two  to  six  millimeters  wide,  according  to  the  requirements 
of  the  case  in  hand.     Gold  prepared  in  this  way  will  bo  found  very 


158  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

effective  in  securing  a  uniformly  dense  and  perfect  wearing  sur- 
face to  fillings.  The  little  pads  after  annealing  should  be  laid 
upon  the  filling  with  their  sides  flat  against  the  surface  and  in 
precisely  the  position  where  it  is  intended  to  condense  them,  and 
each  pad  should  be  thoroughly  condensed  before  another  is  added. 
If  the  final  one-third  of  the  filling  be  built  up  in  this  way  there  will 
be  less  complaint  of  faulty  surfaces,  both  as  regards  wearing 
quality  and  appearance. 

The  form  of  the  different  kinds  of  gold  will  receive  more  de- 
tailed mention  incidentally  with  the  consideration  of  their  intro- 
duction into  the  various  classes  of  cavities. 

Crystal  Golds 

Crystal  gold  is  prepared  by  precipitating  the  gold  into  crystals 
instead  of  by  beating  it  into  foil.  Its  working  qualities  are  some- 
what different  from  foil,  and  its  characteristics  must  be  well 
understood  in  order  to  obtain  good  results.  Some  operators 
seem  to  have  a  peculiar  aptitude  for  manipulating  this  kind  of 
gold,  and  are  able  to  use  it  more  satisfactorily  than  foil,  but  for 
the  great  majority  of  practitioners  it  can  never  be  relied  upon  to 
do  the  same  service  as  foil  in  the  varying  conditions  presented  in 
different  classes  of  cavities.  Its  main  virtue  lies  in  its  tendency 
to  remain  placed  in  the  bottom  of  a  cavity  when  once  forced  there. 
It  does  not  so  readily  curl  away  from  a  wall,  or  rock  under  sub- 
sequent pressure,  as  does  foil,  and  it  is  therefore  indicated  for 
starting  the  filling  in  those  cases  where  the  best  retentive  form 
to  the  cavity  at  this  point  has  not  seemed  possible  of  attainment. 
It  is  also  more  rapidly  condensed  in  a  cavity,  the  filling  apparently 
growing  in  bulk  at  a  greater  rate  of  speed  under  the  plugger  than 
where  foil  is  used;  but  this  very  rapidity  of  growth  may  prove  an 
element  of  insecurity  in  the  constant  danger  of  bridging  over 
spaces  and  leaving  a  filling  imperfect  in  density.  This  may 
readily  occur  with  a  careless  operator,  while  the  surface  of  the 
filling  appears  satisfactory.  The  fact  that  large  masses  of 
crystal  gold  may  be  inserted  into  a  cavity  and  matted  down  to 
place  with  apparent  ease  is  calculated  to  mislead  many  operators. 
These  large  masses  behave  much  Hke  wet  snow  under  pressure — 
they  condense  on  the  surface  but  are  inclined  to  remain  porous 
in  the  depth  of  the  mass.  In  order  to  accomplish  good  results 
with  crystal  gold,  and  do  justice  to  the  material,  the  very  greatest 


GOLD  ■  159 

care  must  be  used  in  its  manipulation.  It  will  not  tolerate  the 
range  of  usage  that  foil  will,  and  unless  an  operator  is  prepared 
to  give  a  careful  study  to  its  peculiar  requirements  he  would 
better  not  employ  it.  The  chief  distinction  in  this  connection 
between  foil  and  crystal  gold  is  that  foil  demands  care,  and  so 
expresses  itself  at  every  turn,  while  the  other  demands  equal  or 
greater  care,  but  seems  constantly  to  give  the  impression  that  it 
does  not. 

As  to  the  form  of  crystal  gold  best  adapted  for  serviceable  work, 
those  preparations  in  which  the  deposit  has  been  carried  on  long 
enough  at  one  time  to  produce  crystals  or  spicules  of  considerable 
length  would  seem  to  offer  the  greatest  promise  of  usefulness,  both 
as  to  strength  of  the  finished  product  and  convenience  of  manipu- 
lation. A  mat  of  gold  formed  of  small  crystals  is  granular  in 
structure.  It  is  easily  disintegrated  in  handling,  and  crumbles 
so  as  to  waste  extensively;  while  a  filling  made  from  it  cannot  be 
expected  to  present  the  same  strength  in  a  given  mass  that  would 
one  made  from  gold  of  a  more  fibrous  nature.  Another  important 
consideration  in  this  connection  is  that  a  fibrous  gold  may  be 
expected  to  result  in  better  margins  to  the  filling  than  one  of  a 
granular  structure.  One  serious  limitation  to  some  of  the  crystal 
golds  offered  in  the  past  has  been  the  insecurity  of  the  material 
when  built  over  beveled  enamel-margins,  on  account  of  the 
tendency  to  disintegrate  and  crumble  away.  The  more  perfectly 
the  fibrous  arrangement  is  maintained,  the  greater  strength  may 
be  expected  of  the  material. 

The  main  points  to  be  considered  in  manipulating  crystal  gold 
relate  to  accuracy  in  placing  each  pellet  as  it  is  carried  to  the 
cavity,  to  a  careful  selection  of  the  cases  suitable  for  its  use,  and 
to  the  proper  form  of  plugger-points.  Each  piece  of  gold  should 
be  carried  precisely  to  the  spot  where  it  is  intended  to  condense  it, 
and  it  should  not  be  disturbed  by  too  much  manipulation  before  it 
is  condensed.  It  is  quite  impossible,  with  crystal  gold  of  good 
cohesive  texture,  to  move  a  pellet  of  it  across  the  surface  of  the 
gold  already  in  the  cavity  for  the  purpose  of  securing  a  more  con- 
venient position.  Any  attempt  to  insinuate  it  out  of  the  location 
first  taken  will  result  in  tearing  the  uncondensed  pellet  so  that  it 
is  disintegrated  and  wasted. 

The  places  where  crystal  gold  is  indicated  are  in  starting  fillings 
in  difiicult  cases,  and  in  large,  open  cavities  easy  of  access,  where 
the  gold  may  be  conveniently  laid  on  in  regular  arrangement  and 


160  PRINCIPLES    AND    PRACTICE    OP    FILLING    TEETH 

condensed  under  the  eye  of  the  operator.  It  should  not  be  em- 
ployed for  filling  undercuts  or  remote  positions  in  cavities,  on 
account  of  the  tendency  to  bridge. 

The  pluggers  best  adapted  to  its  use  are  the  oval-faced  forms, 
with  shallow  serrations.  For  starting  the  filling  a  large  point 
should  be  used,  with  vigorous  hand-pressure,  to  carry  the  mass  in 
front  of  the  plugger  instead  of  puncturing  it;  but  as  the  filling  is 
being  built  up  too  large  points  must  not  be  used,  for  fear  of  failure 
in  density.  A  convenient  method  of  condensing  the  main  portion 
of  the  filling  and  securing  an  even  surface  is  to  use  a  rapid  mallet 
with  the  Royce  plugger-points.  These  points,  being  oval  on  their 
serrated  ends,  may  be  swept  back  and  forth  across  the  surface 
of  the  fining  with  little  danger  of  tearing  the  uncondensed  gold 
away  and  wasting  it,  as  is  sometimes  the  result  with  flat-faced 
pluggers.  The  Royce  pluggers  should  be  held  a  short  distance 
from  the  condensed  surface,  so  that  the  jump  of  the  mallet 
catches  the  gold  in  front  of  the  plugger  and  mats  it  to  place. 


CHAPTER  VIII 

MALLETS  AND  MALLETING 

The  selection  of  a  mallet  for  the  insertion  of  gold  is  a  matter 
which  must  be  left  largely  to  the  individual  preference  of  the 
operator,  and  yet  there  are  distinguishing  characteristics  related 
to  the  different  forms  of  mallet  which  call  for  consideration. 
Laying  aside  the  factor  of  personal  equation,  we  must  not  ignore 
some  of  the  fundamental  qualities  inherent  in  the  nature  of  the 
appliance  which  influence  its  practical  utility. 

The  Hand  MaUet 

This  mallet  was  the  first  to  be  used  for  condensing  gold,  and  it 
would  seem  to-day  to  be  capable  of  a  wider  range  of  service  than 
any  other  single  form  of  mallet.  No  other  mallet  yet  suggested 
has  so  many  advantages  with  so  few  disadvantages.  Its  chief 
limitation  relates  to  the  necessity  of  employing  an  assistant  to 
manipulate  it,  owing  to  the  fact  that  the  operator  has  too  many 
uses  for  his  left  hand  to  make  it  convenient  for  him  to  employ  it 
for  this  purpose.  It  is  true  that  some  practitioners  prefer  to  do 
their  own  malleting,  and  by  constant  practice  become  very  expert, 
but  in  the  daily  routine  of  gold  filling  there  are  too  many  demands 
on  an  operator's  vitality  without  adding  to  them  in  this  particular. 
No  operator  can  do  his  own  maUeting  without  placing  himself  in  a 
more  strained  position  than  would  be  necessary  if  some  one  else 
malleted,  and  there  are  times  when  it  seems  almost  imperative  to 
utilize  both  hands  for  other  purposes.  While  it  may  be  possible 
to  strike  a  more  intelligent  blow  and  regulate  the  force  more 
accurately  to  the  requirements  of  the  case,  yet  the  method  calls 
for  too  great  a  tax  on  the  operator  to  make  it  desirable  practice. 

The  Assistant. — The  problem  of  training  an  assistant  to  be  a 
good  malleter  is  a  necessary  concomitant  to  success  in  the  use  of 
the  hand  mallet.  Usually  a  young  lady  assistant  is  best  suited  to 
this  purpose — one  who  has  no  intention  of  studying  dentistry  as  a 
profession.  The  reason  for  this  is  that  to  be  an  expert  malleter 
11  161 


162  PRINCIPLES   AND    PRACTICE    OF    FILLING    TEETH 

the  assistant  should  have  no  interest  in  the  operation  except  to  use 
the  mallet.  A  student  of  dentistry  naturally  becomes  interested 
in  the  progress  of  the  filling,  and  is  inclined  to  divert  the  attention 
occasionally  to  the  tooth  instead  of  concentrating  it  solely  upon 
the  end  of  the  plugger  handle.  This  diversion  results  in  imper- 
fect work,  and  any  imperfection  on  the  part  of  the  assistant 
renders  the  hand  mallet  almost  the  worst  that  can  be  used.  The 
quickest  perception  is  necessary  to  anticipate  every  move  of  the 
operator,  and  a  young  lady  usually  possesses  this  intuitive  per- 
ception to  a  greater  degree  than  the  average  young  man.  A  nod 
of  the  operator's  head  or  the  slightest  intimation — so  slight,  in 
fact,  that  the  patient  need  never  be  cognizant  of  it — is  all  that 
should  be  necessary  to  indicate  to  a  capable  assistant  the  charac- 
ter of  blow  required,  whether  as  to  force  or  rapidity  of  stroke. 
The  assistant  should  be  trained  to  develop  the  wrist  to  the  highest 
degree  of  suppleness,  so  that  in  striking  the  blow  there  shall  be 
an  entire  absence  of  arm-weight  exerted  upon  the  mallet.  She 
should  also  learn  to  use  either  hand  with  equal  facihty,  but  in 
the  event  of  one  hand  being  developed  to  a  higher  degree  of 
perfection  than  the  other,  preference  should  be  given  to  the  left 
hand,  on  account  of  the  fact  that  during  most  operations  the 
assistant  must  stand  on  the  left  side  of  the  patient,  facing  the 
operation,  thus  giving  the  left  hand  the  widest  range  of  usefulness. 

One  of  the  most  important  considerations  in  the  use  of  the  hand 
mallet  relates  to  the  angle  at  which  the  mallet  meets  the  plugger. 
The  striking  face  of  the  mallet  should  be  at  direct  right  angles 
with  the  long  axis  of  the  plugger,  or,  in  other  words,  the  mallet 
should  strike  the  plugger  squarely  on  the  end  at  every  blow. 
Any  deviation  from  this  results  in  a  glancing  of  the  mallet  across 
the  end  of  the  plugger,  which  interferes  with  its  condensing  power 
and  proves  very  distressing  to  the  patient.  To  invariably  strike 
a  square  blow  necessitates  the  constant  attention  of  the  assistant, 
added  to  a  quick  anticipation  of  any  change  in  the  angle  made  by 
the  operator,  so  as  to  meet  it  with  a  corresponding  change  in  the 
direction  of  the  mallet  blow.  There  should  be  developed  between 
the  operator  and  malleter  the  closest  concert  of  action,  and  the 
one  should  understand  the  methods  of  the  other  so  perfectly  that 
no  verbal  instruction  is  necessary  during  an  operation.  This  har- 
mony of  procedure  is  very  reassuring  to  a  patient  and  leads  to 
confidence  in  both  operator  and  assistant. 

The  Kind  of  Mallet. — In  1871  the  late  Dr.  James  Truman,  of 


MALLETS    AND    MALLETING  163 

Philadelphia,  conducted  a  series  of  experiments  with  a  view  of 
determining  the  kind  of  mallet  best  suited  to  the  condensation 
of  gold,  and  later  Dr.  Clayton  H.  Stearns,  of  Owatonna,  Minn., 
threw  additional  light  on  the  subject  in  papers  read  before  the 
Minnesota  State  Dental  Society  and  the  National  Dental  Asso- 
ciation. Though  the  methods  of  investigation  of  these  two  men 
were  different  in  technique,  their  conclusions  were  in  many  re- 
spects similar  so  far  as  the  essentials  of  their  findings  were 
concerned. 

The  questions  to  be  determined  were  the  relative  condensing 
power  of  mallets  of  different  weights  and  of  different  materials, 
upon  bases  of  varying  degrees  of  hardness  or  softness  as  a  medium 
of  resistance  to  the  mallet  impact.  Assuming  that  a  tooth  in  the 
mouth  is  a  partially  non-resisting  body.  Dr.  Truman's  con- 
clusions were  summed  up  as  follows: 

^^ First. — That  hand  pressure  in  the  mouth  can  never  condense 
as  thoroughly  as  the  mallet. 

^'Second. — That  weight  cannot  entirely  overcome  mobility. 

''  Third. — That  density  and  velocity  are  requisite  in  a  mallet. 

'^Fourth. — That  for  hand  malleting,  the  light  steel  mallet  is  to 
be  preferred." 

It  was  found  that  hand  pressure  on  a  hard  resisting  base  such 
as  wood  gave  very  nearly  as  good  results  as  the  light  steel  mallet 
on  a  similar  base,  but  that  the  softer  the  base  the  greater  the 
advantage  in  favor  of  the  light  mallet.  It  remains  somewhat  of 
a  question  as  to  the  precise  character  of  base  the  teeth  present. 
In  some  instances  they  are  undoubtedly  to  a  large  degree  non- 
resisting,  on  account  of  impairment  of  the  pericemental  mem- 
brane, but  in  other  cases  where  they  are  firmly  set  in  the  jaws 
they  are  at  least  sufficiently  resisting  to  justify  the  judicious  use 
of  hand  pressure  in  those  positions  where  the  mallet  impact 
cannot  conveniently  reach. 

Dr.  Truman  found  in  a  rapid  mallet  such  as  the  electric  a 
combination  of  desirable  qualities  which  made  it  almost  the 
ideal  instrument  for  condensing  gold.  It  had  density  and  ve- 
locity, which  he  laid  down  as  requisites  in  a  mallet,  but  in  its 
application  in  the  mouth  the  rapid  mallet  has  its  limitations, 
which  will  be  considered  later. 

Dr.  Stearns  also  favored  the  light  steel  hand  mallet,  but 
varied  somewhat  from  Dr.  Truman  in  his  recommendation  as 
to  what  is  most  serviceable  for  practical  work  in  the  mouth. 


164  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

He  advocated  a  heavy  lead  mallet — or  lead  covered  with  leather 
— for  starting  fillings  with  non-cohesive  gold  where  large  pieces  of 
the  material  are  used  and  the  impact  requires  to  be  carried 
through  the  mass  of  gold  to  the  wall  of  the  cavity;  this  to  be 
followed  by  a  2-oz.  steel  mallet  for  building  the  bulk  of  the 
filling,  and  finally  the  3^-oz.  hardened  steel  mallet  to  go  over 
the  surface. 

The  idea  seems  to  be  that  the  heavier  the  mallet  and  the  softer 
the  material  of  which  it  is  made  the  farther  the  impulse  is  carried 
beyond  the  immediate  point  of  impact,  while  the  lighter  the 
mallet  and  the  harder  the  material  the  more  the  energy  is  con- 
centrated. For  instance,  if  we  strike  a  blow  on  a  gold  filling 
with  a  6-oz.  lead  mallet  the  jar  is  felt  throughout  the  entire  head  of 
the  patient,  the  impulse  being  carried  on  beyond  the  tooth,  and 
the  sensation  in  the  tooth  itself  not  being  especially  pronounced. 
But  let  us  strike  the  same  tooth  as  nearly  as  possible  the  same 
blow  with  a  )-^-oz.  hardened  steel  mallet  and  the  energy  seems 
concentrated  right  in  the  tooth  with  little  jarring  of  the  head. 
As  one  patient  aptly  put  it,  ''That  little  hammer  stings  the  tooth 
every  time  it  hits." 

This  question  of  the  impression  made  on  the  patient  by  the 
various  mallets  becomes  an  important  factor  in  the  selection  of  a 
suitable  one  for  the  mouth,  for  however  much  we  might  wish  to 
follow  the  mechanical  philosophy  of  the  mallet  in  our  operations 
we  must  not  ignore  the  sensibilities  of  the  patient. 

With  the  principles  of  Drs.  Truman  and  Stearns  in  mind,  and 
with  a  very  close  study  of  the  behavior  of  mallets  in  the  mouth 
and  the  varying  susceptibilities  of  patients  in  this  regard,  it  would 
seem  that  in  the  majority  of  cases  the  best  results  were  to  be  ob- 
tained in  the  following  way: 

For  starting  fillings  where  the  object  is  to  adapt  large  masses 
of  non-cohesive  gold  to  the  cavity  walls,  or  where  we  wish  to  drive 
the  first  pieces  of  cohesive  gold  into  the  structure  of  the  non- 
cohesive — -in  other  words,  where  we  wish  the  impulse  carried 
through  an  appreciable  mass — we  should  use  a  heavy  lead  or 
leather-covered  mallet.  For  building  the  bulk  of  the  filling,  if 
the  patient  can  tolerate  it  the  2-oz.  steel  mallet  is  probably 
more  effective  in  giving  uniform  density  to  the  gold  in  the  size  of 
pellets  we  ordinarily  use  for  this  purpose  than  any  other  form  of 
mallet.  There  is  one  feature  of  this  mallet  that  recommends  it 
highly  for  definite  and  precise  work  in  building  gold.     With  it 


MALLETS    AND    MALLETING  165 

the  experienced  operator  can  tell  instantly  by  the  sensation 
conveyed  through  the  plugger  just  when  the  gold  is  dense.  He 
need  not  have  one  extra  blow  struck  after  density  is  reached-y 
which  cannot  always  be  said  when  a  soft  mallet  is  used. 

But  there  are  some  patients  who  are  so  profoundly  affected  by 
the  ring  of  a  steel  mallet  that  it  is  only  common  humanity  to 
dispense  with  it  and  use  the  lead  mallet  for  building  the  filling, 
even  if  in  so  doing  we  may  sacrifice  some  of  the  hardness  that 
would  naturally  be  imparted  by  the  steel  mallet.  For  the 
surfaces  of  all  fillings  the  H-oz-  steel  mallet  will  be  found  to 
give  a  ringing  hardness  to  the  gold  that  cannot  be  approached  by 
the  use  of  any  of  the  heavier  or  softer  mallets,  and  after  the  first 
few  stinging  blows  the  patient  can  usually  tolerate  this  light 
mallet  with  little  inconvenience. 

The  prime  objects  to  be  attained  in  condensing  a  gold  filling 
may  be  summarized  as  follows : 

First. — To  perfectly  seal  the  cavity  against  leakage. 
Second. — To  so  compress  the  layers  of  foil  throughout  the 
filling  that  the  mass  will  be  free  from  air-spaces. 

Third. — To  render  the  surface  of  the  filling  sufficiently  hard 
to  withstand  the  usage  it  is  likely  to  receive  in  the  mouth. 

The  first  of  these  calls  for  close  adaptation  of  the  gold  to  the 
cavity-walls,  and  this  can  best  be  obtained  in  most  instances 
by  the  use  of  non-cohesive  gold  driven  to  place  in  appreciable 
masses.  In  every  case  where  gold  is  being  adapted  to  walls  of 
cavities  it  is  necessary  to  have  a  sufficient  layer  of  gold  between 
the  wall  and  the  plugger  to  insure  against  injury  to  the  wall  by 
the  point  of  the  plugger.  This  is  especially  true  in  starting 
fillings,  and  for  this  purpose  the  driving  force  of  the  heavy  soft 
mallet,  carrying  the  impulse  some  distance  in  advance  of  the 
point  of  appHcation,  seems  particularly  well  adapted.  For  weld- 
ing the  layers  of  gold  together  in  the  bulk  of  the  filling  the  driving 
force  is  not  so  necessary — especially  where  the  pellets  of  gold 
are  laid  on  in  regular  arrangement  as  they  should  be — and 
the  lighter,  harder  mallet  is  indicated.  Theoretically  the  lightest 
steel  mallet  should  do  this  work  well,  but  there  is  one  feature  of 
the  K-oz.  steel  mallet  which  militates  against  its  practical  use  in 
the  mouth  for  the  purpose  of  filling-building.  The  energy 
developed  is  at  such  high  tension  that  the  least  over-malleting 
results  in  raising  the  molecular  tension  of  the  gold  to  such  an 
extent  as  to  interfere  with  its  cohesion.     In  other  words,  if  a 


166  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

light  steel  mallet  is  used  on  the  surface  of  a  filling  and  the 
malleting  carried  too  far  it  will  be  found  impossible  to  make 
another  piece  of  gold  adhere  to  it.  The  gold  in  the  filling  would 
have  to  be  annealed  again  to  make  it  cohesive.  This  does  not 
imply  that  a  good  filling  cannot  be  built  with  this  mallet,  but 
simply  that  in  the  hands  of  the  average  operator  it  will  prove 
treacherous. 

This  is  one  reason  why  the  rapid  mallet  has  not  been  more  gen- 
erally used.  Operators  have  found  that  occasionally  the  gold 
would  fail  to  cohere  with  it,  and  it  is  only  among  the  few  who 
have  mastered  its  peculiarities  so  as  to  know  intuitively  when  to 
stop  malleting  that  the  instrument  has  been  a  success.  A  careful 
study  of  this  matter  will  give  a  wider  range  of  usefulness  to  the 
lighter  mallets  in  building  fillings. 

A  statement  of  the  third  requisite  in  condensing  gold,  viz.,  the 
hardening  of  the  surface,  would  imply  that  it  is  possible  to  render 
gold  harder  even  after  the  layers  are  perfectly  welded  together, 
and  this  is  true.  A  soft  heavy  mallet  may  bring  the  layers  in 
close  apposition  to  each  other,  but  it  can  never  make  the  surface 
so  hard  as  the  repeated  impact  of  the  light  steel  mallet.  This 
can  readily  be  demonstrated  by  any  operator  who  tests  it  on  his 
fillings. 

A  thorough  study  of  the  principles  involved  in  the  use  of  the 
mallet  in  building  gold  fillings  is  strongly  urged  upon  every  den- 
tist, and  to  this  end  the  conclusions  of  Drs.  Stearns  and  Truman 
as  summarized  in  the  transactions  of  the  National  Dental  Associa- 
tion, 1901,  will  be  found  very  valuable  for  reference. 

The  Automatic  Mallet 

This  mallet  was  devised  to  avoid  the  necessity  of  employing  an 
assistant,  and  in  the  hands  of  some  operators  it  seems  to  be  an 
efficient  appliance.  But  it  may  well  be  doubted  whether  it  is 
ever  capable  of  the  same  degree  of  delicacy  that  is  easily  attained 
with  the  hand  mallet,  or  whether  for  most  patients  it  can  be 
compared  to  the  hand  mallet  when  comfort  is  considered.  Given 
an  expert  assistant  in  a  test  of  the  two  forms  of  mallets,  and 
probably  nine  out  of  ten  patients  will  select  the  hand  mallet. 
There  is  a  feature  of  the  automatic  mallet  which  doubtless  may 
be  held  in  some  degree  accountable  for  this  aversion  on  the  part 
of  patients.  In  order  to  obtain  the  blow  it  is  necessary  to  exert 
pressure  on  the  filling  with  the  plugger-point,  and  this  pressure 


MALLETS    AND    MALLETING  167 

carried  to  a  certain  limit,  causing  a  sudden  recoil  and  blow, 
creates  in  the  mind  of  the  patient  a  series  of  anticipations  which 
in  the  aggregate  become  exhausting.  In  other  words,  the  patient 
is  continually  being  warned  by  the  pressure  that  a  blow  is  to 
be  struck,  and  this  repeated  leading  up  to  the  blow  by  pressure 
keeps  the  patient  constantly  on  a  tension.  The  precise  charac- 
ter of  the  discomfort  is  not  always  capable  of  analysis  by  patients, 
and  they  are  often  unable  to  explain  why  they  dislike  the  auto- 
matic mallet,  but  if  this  matter  be  carefully  watched  by  the 
operator  he  will  soon  ascertain  that  there  is  invariably  an  in- 
tuitive flinching  on  the  part  of  the  patient  whenever  the  pressure 
of  the  plugger  is  prolonged  beyond  the  ordinary.  It  seems  to  be 
this  interval  of  suspense  which  is  trying  to  the  patient  more  than 
the  actual  blow.  All  of  this  is  avoided  by  the  hand  mallet. 
There  is  no  advance  pressure  to  herald  the  coming  blow,  and  the 
character  of  the  stroke  is  short,  sharp,  decisive,  and  instantly 
over. 

This  recalls  one  feature  of  an  automatic  which  would  seem  to 
have  an  important  bearing  on  its  utihty.  The  stroke  should  be 
as  short  as  possible  consistent  with  volume  of  blow.  Most  auto- 
matic mallets  have  so  long  a  stroke  that  their  manipulation  is  a 
slow  and  awkward  process,  besides  adding  materially  to  the  ele- 
ment of  discomfort.  An  automatic,  to  do  the  best  service  capable 
of  such  an  instrument,  should  work  with  a  short,  snappy  blow, 
definite  in  quality  and  with  a  rapid  rebound,  so  as  never  to  miss 
a  stroke.  To  attain  this  the  appliance  must  be  kept  in  the  most 
perfect  condition  by  repeated  cleansing  and  oiling. 

The  Rapid  MaUets 

Each  of  the  various  forms  of  rapid  mallets  has  its  adherents 
among  operators,  but  probably  the  ones  most  in  use  are  the 
mechanical  or  pneumatic  mallets  operated  by  the  engine  or  by  a 
motor.  The  electric  mallet  seems  largely  to  have  been  displaced 
by  others  more  readily  kept  under  control  and  less  complicated. 
It  would  seem  that  the  ideal  rapid  mallet  was  one  which,  besides 
giving  a  definite  blow  at  any  desired  speed,  may  be  run  by  the 
motor. 

The  only  places  suited  for  a  rapid  mallet  are  in  cavities  ready  of 
access,  where  it  is  merely  a  matter  of  laying  on  the  gold,  and  also 
for  finishing  the  surfaces  of  fillings  after  the  inaccessible  parts  of 
the  cavity  have  been  filled.     It  is  hazardous  to  attempt  to  build 


168  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

gold  around  corners  or  to  reach  difficult  positions  with  the  rapid 
mallet.  Such  an  effort  usually  results  in  bridging  the  gold  over 
spaces,  and  fails  in  perfect  protection  of  cavity- walls  in  the 
inaccessible  regions. 

It  is  often  an  agreeable  change  for  the  patient  to  have  the 
rapid  mallet  substituted  for  the  hand  or  automatic  mallet  as  the 
filling  nears  completion.  Any  diversion  in  the  character  of  the 
blow  seems  to  afford  relief  from  the  monotony  of  a  long  sitting, 
and  to  be  more  acceptable  to  most  patients  than  the  continued 
use  of  any  one  kind  of  blow  throughout  the  entire  filling.  For 
this  purpose  the  rapid  mallet  becomes  very  useful,  and  it  also 
materially  shortens  the  operation.  Gold  may  be  condensed  on 
an  accessible  surface  almost  as  rapidly  as  the  pellets  can  be  carried 
to  the  tooth  and  placed  by  the  assistant.  This  mallet  also  leaves 
a  surface  even  and  dense,  if  its  manipulation  be  well  understood. 

The  proper  method  of  using  a  rapid  mallet  is  to  sweep  the 
plugger  point  across  the  surface  of  the  filling  from  center  to 
margin,  as  if  the  gold  were  being  wiped  into  the  cavity.  The 
process  is  entirely  different  from  that  of  the  hand  or  automatic 
mallet,  and  this  fact  should  be  recognized  by  those  who  attempt 
to  use  it.  Care  should  be  exercised  not  to  over-mallet  and  de- 
stroy the  cohesion  of  the  gold,  to  which  reference  has  already  been 
made. 

As  before  intimated,  oval-faced  pluggers  with  shallow  serrations 
are  indicated  for  the  rapid  mallet,  whereby  the  gold  may  be  wiped 
down  on  the  filling  instead  of  being  caught  by  the  side  of  the 
plugger  and  torn  off  laterally,  as  would  be  likely  to  result  with  a 
flat-faced  plugger  having  a  sharp  angle  between  the  serrated  end 
and  the  shank.  Another  advantage  of  oval-faced  pluggers  relates 
to  the  safety  of  enamel-margins.  The  rapid  mallet  carrying  a 
plugger  with  sharp  angles  is  exceedingly  prone  to  chop  up  or 
pulverize  the  margins  unless  the  greatest  care  is  exercised,  but  the 
oval-faced  pluggers  will  permit  greater  freedom  of  action  without 
injury.  This  watchful  care  of  the  enamel-margins  is  one  of  the 
necessary  precautions  in  the  use  of  any  rapid  mallet,  and  no  opera- 
tor should  attempt  to  use  such  an  appliance  without  due  apprecia- 
tion of  its  dangers  in  this  respect. 

Hand  Pressure 

If  an  operator  were  rigidly  confined  to  any  one  process  for  the 
insertion  of  gold,  it  is  probable  that  he  would  do  better  service 


MALLETS    AND    MALLETING  169 

for  his  patient  in  the  varying  conditions  presented  in  the  mouth 
by  the  use  of  hand  pressure  than  by  any  other  one  method,  and 
yet  the  places  where  hand  pressure  is  properly  indicated  are 
comparatively  limited.  The  great  bulk  of  our  work  is  better 
accomplished  by  mallet  force,  but  in  those  occasional  locations 
demanding  hand  pressure  there  seems  to  be  nothing  else  which 
will  at  all  adequately  take  its  place.  In  distal  cavities  in  molars 
and  bicuspids  there  is  often  a  certain  region  which  cannot  be 
reached  by  a  direct  blow  of  the  mallet,  and  unless  the  operator 
recognizes  this  fact  and  resorts  to  hand  pressure  in  building  up 
the  filling  at  these  points  he  will  fail  of  perfect  protection  to  the 
cavity-walls.  These  inaccessible  locations  are  usually  repre- 
sented by  the  wall  of  the  cavity  which  stands  nearest  to  the 
operator,  or,  in  other  words,  whose  face  is  presented  away  from 
the  operator  so  that  it  cannot  be  seen  except  with  a  mirror. 

For  instance,  in  a  disto-occlusal  cavity  on  a  right  lower  molar 
the  buccal  wall  of  the  cavity  can  seldom  be  seen  by  the  unaided 
eye,  and  the  relation  of  the  operator  to  this  wall  is  such  that 
direct  mallet  force  against  it  is  impossible.  In  a  case  like  this 
the  only  certain  means  of  securing  adaptation  of  the  gold  to  the 
wall  is  by  the  use  of  right-angle  pluggers  wielded  by  hand  pres- 
sure. When  these  cavities  are  on  the  distal  surfaces  of  teeth  far 
back  in  the  mouth,  or  where  the  muscles  of  the  lips  are  tense  and 
unyielding,  it  is  often  necessary  to  build  the  entire  gingival 
third — or  even  half — of  the  filling  by  hand  pressure. 

The  right-angle  mallets  devised  as  a  substitute  in  the  various 
cases  indicated  are  useful  in  the  hands  of  some  operators  under 
certain  conditions,  but  it  would  seem  impossible  to  get  so  accurate 
a  placing  of  the  gold  by' their  use  as  by  hand  pressure.  The  gold 
can  be  "pulled"  .against  inaccessible  places  or  insinuated  under 
overhanging  walls  where  such  conditions  are  encountered  with 
greater  precision  by  hand  pressure  than  by  any  mallet  force. 
The  pluggers  used  for  the  purpose  should  have  a  very  stiff  shank 
with  a  large  handle,  capable  of  being  conveniently  grasped  in  the 
palm,  by  which  means  most  of  the  pulKng  force  is  best  exerted. 
In  order  to  be  assured  of  perfect  adaptation  and  an  adequate 
degree  of  density  with  hand  pressure,  it  is  necessary  to  exert 
considerable  force,  and  the  plugger  should  be  strong  and  the  wall 
sufficiently  thick  to  safely  sustain  this  force.  This  recalls  a 
certain  mistaken  idea  which  appears  to  be  prevalent  among 
operators  as  to  the  indications  for  and  against  hand  pressure. 


170  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

The  impression  would  seem  to  prevail  that  hand  pressure  is 
indicated  when  building  along  frail  walls  or  over  friable  enamel. 
The  exact  contrary  is  the  fact.  No  operator  can  with  hand 
pressure  secure  the  same  degree  of  density  or  adaptation  along 
weak  walls  that  can  safely  be  obtained  by  delicate  blows  of  the 
mallet.  This  is  particularly  true  of  the  hand  mallet  wielded  by  a 
trained  assistant. 

One  place  where  hand  pressure  is  useful  relates  to  the  starting 
of  all  fillings.  This  can  be  readily  accomplished  on  the  wedging 
principle  with  non-cohesive  gold,  and  the  first  pieces  of  cohesive 
gold  may  also  often  be  carried  to  place  and  fastened  into  the  sub- 
stance of  the  non-cohesive  to  good  advantage  with  hand  pressure. 
For  this  purpose  a  certain  manner  of  manipulating  the  plugger 
should  be  observed,  in  order  to  obtain  the  most  perfect  results. 
It  is  seldom  that  a  straight  pushing  or  pulling  force  will  prove  as 
effective  as  will  the  same  degree  of  force  exerted  with  a  wrist  move- 
ment whereby  the  point  of  the  plugger  is  held  on  the  gold  and  the 
end  of  the  handle  is  swayed  back  and  forth  so  as  to  describe  the 
short  arc  of  a  circle.  If  a  right-angle  plugger  is  being  used,  the 
swaying  should  occur  at  the  angle.  This  insinuating  spreading 
force  accomplishes  two  objects:  it  carries  the  gold  into  every  in- 
equality in  the  wall  of  the  cavity,  securing  perfect  adaptation, 
and  the  swaying  motion  also  presses  the  uncondensed  portion  of 
the  pellet  which  has  curled  up  around  the  shank  away  from  the 
plugger,  allowing  the  instrument  to  be  withdrawn  without  carry- 
ing the  pellet  with  it. 

This  same  method  of  manipulation  is  very  effective  when  for 
any  reiason  not  apparent  to  the  operator  a  pellet  of  gold  fails  to 
adhere  to  the  surface  of  the  filling  under  mallet  force.  A  rebel- 
lious pellet  may  be  fastened  to  the  filling  by  hand  pressure  exerted 
as  just  indicated,  and  made  to  remain  more  securely  than  by 
mallet  force.  The  rocking  motion  of  the  plugger  insinuates  the 
substance  of  the  loose  pellet  into  the  structure  of  the  condensed 
gold  and  pins  it  to  place  to  better  advantage  than  if  the  mere 
property  of  surface  cohesion  were  the  sole  dependence.  For 
this  purpose  a  plugger  point  with  clean-cut,  sharp  serrations  is 
indicated,  and  after  several  pieces  have  been  added  to  the  filling 
in  this  way  it  should  be  followed  by  the  mallet  over  the  surface 
to  insure  uniformity  of  density. 

It  may  be  here  stated  that  a  more  satisfactory  wearing  surface 
can  be  given  to  any  filling  with  mallet  force  than  is  possible 


MALLETH    AND    MALLETING  171 

with  hand  pressure,  though  hand  pressure  fillings  properly  inserted 
usually  succeed  in  saving  the  teeth.  They  do  so  by  reason  of 
good  adaptation  to  the  cavity-walls,  thus  preventing  leakage, 
even  in  many  cases  where  the  wearing  surface  of  the  filling  be- 
comes pitted  and  unsatisfactory.  No  filling  which  is  subjected  to 
the  attrition  of  mastication  should  be  considered  safe,  so  far  as  the 
condition  of  its  surface  is  concerned,  unless  the  mallet  has  been 
employed  in  finishing  the  filling  to  impart  a  resisting  property 
to  the  gold. 

Protection  to  the  Pericemental  Membrane  in  Malleting 

The  problem  of  securing  sufficient  density  to  a  gold  filling  so 
that  it  may  safely  withstand  the  usage  to  which  it  is  subjected  in 
the  mouth  without  causing  too  much  punishment  to  the  peri- 
cemental membrane  during  the  operation,  is  one  which  confronts 
the  practitioner  on  approaching  any  cavity  of  considerable  size. 
The  pericemental  membrane  is  more  or  less  elastic,  and  when  a 
blow  is  struck  on  the  tooth  with  a  mallet  the  tooth  is  forced 
slightly  into  the  alveolus,  causing  a  compression  of  the  membrane. 
Instantly  following  this  impact  the  membrane  reasserts  itself, 
forcing  the  tooth  out  again  to  its  original  position.  Another  blow 
drives  it  against  the  membrane  once  more,  and  the  membrane 
again  reacts.  This  repeated  forcing  in  and  out  of  the  tooth  soon 
results  in  such  impairment  of  the  membrane  that  if  the  process 
is  kept  up  sufficiently  long  without  protection  the  operator  is 
finally  pounding  the  tooth  on  a  jellied  membrane. 

This  stage  of  injury  is  reached  much  sooner  in  those  cases 
where  the  teeth  have  recently  been  wedged  apart  and  are  corre- 
spondingly loose,  and  this  one  factor  becomes  an  important  con- 
sideration in  the  choice  of  methods  for  gaining  space  as  between 
previous  wedging  and  the  use  of  a  separator.  Wherever  sufficient 
space  can  be  safely  gained  with  a  separator  it  will  ordinarily 
result  in  less  aggregate  discomfort  to  the  patient  than  will  the 
process  of  previous  wedging  followed  by  an  operation  while  the 
tooth  is  still  loose.  One  important  office  of  the  separator  is  to 
hold  the  tooth  firm  against  movement  under  the  impact  of  the 
mallet,  and  it  may  often  be  profitably  employed  during  an  opera- 
tion for  this  purpose  alone  in  cases  where  space  has  previously 
been  gained  by  wedging.  In  those  instances  where  it  has  been 
necessary  to  wedge  extensively,  thus  causing  so  great  a  movement 


172  PRINCIPLES    AND    PRACTICE    OF   FILLING    TEETH 

of  the  teeth  that  they  are  left  loose  and  sore,  the  operation  of 
filling  should  invariably  be  deferred  till  the  soreness  subsides. 
The  teeth  may  be  held  apart  during  this  interval  with  gutta- 
percha. 

The  whole  problem  of  protecting  the  membrane  against  injury 
from  mallet  force  relates  to  giving  the  tooth  such  support  that  it 
is  held  firm  and  immovable  under  the  blow.  This  may  be  ac- 
complished in  various  ways,  each  case  suggesting  the  method 
most  suited  to  itself.  Sometimes  a  wooden  wedge  may  be  used 
for  this  purpose,  or  a  separator  as  already  indicated,  but  for  an 
extended  operation  the  surest  means  is  to  hold  an  instrument  in 
the  left  hand  braced  firmly  against  the  tooth  or  filling  through- 
out the  operation.  This  kind  of  support  is  especially  indi- 
cated as  the  filling  nears  completion  on  account  of  the  tend- 
ency to  soreness  at  that  time,  and  also  because  the  surface  of  the 
filling  requires  the  most  thorough  malleting  to  be  assured  of 
adequate  density.  If  a  tooth  be  protected  in  this  way  the 
membrane  will  ordinarily  not  rebel  against  mallet  force  sufficient 
to  condense  gold  into  a  serviceable  filling,  except  in  those  cases 
where  the  membrane  is  impaired  or  is  hypersensitive.  When 
a  tooth  is  loose  from  absorption  of  the  alveolar  process  or  from 
inflammation  of  the  soft  parts  surrounding  it,  a  gold  filling  of 
any  size  should  not  be  attempted  in  it  till  the  tooth  is  made  firm 
by  treatment.  If  it  cannot  be  made  firm  the  operator  would 
better  select  some  other  filling-material,  or  insert  an  inlay. 

In  some  instances  the  pericemental  membrane  is  so  weakened 
through  lack  of  use  that  it  is  painfully  responsive  to  mallet  force. 
This  is  ordinarily  brought  about  by  the  fact  that  when  caries 
occurs  the  tooth  becomes  sensitive  to  mastication,  and  the  patient 
involuntarily  avoids  its  use  to  the  end  that  the  membrane, 
lacking  its  normal  functional  exercise,  deteriorates  in  its  resistive 
qualities  so  as  to  quickly  rebel  against  the  mallet.  The  remedy  for 
this  condition  lies  in  subjecting  the  tooth  to  masticatory  usage  in 
advance  of  the  operation,  by  placing  in  the  cavity  a  gutta-percha 
plug  to  control  the  sensitiveness  and  instructing  the  patient  to 
bring  the  tooth  into  active  service.  In  this  way  the  membrane 
may  be  so  toughened  in  a  week  or  ten  days  as  to  receive  the  im- 
pact of  the  mallet  comfortably. 

Another  consideration  connected  with  the  toleration  of  the  mem- 
brane to  mallet  force  relates  to  the  direction  in  which  the  pressure 
is  brought  to  bear  upon  the  tooth.     If  the  condensation  of  the 


MALLETS    AND    MALLETING  173 

gold  takes  place  in  line  with  the  length  of  the  root,  it  will  be  found 
that  there  is  less  soreness  than  where  an  equal  force  is  exerted 
against  the  tooth  laterally.  With  this  idea  in  mind,  all  fillings 
requiring  extended  maletting  should  be  so  built,  if  possible,  that 
the  pellets  of  gold  are  laid  at  right  angles  to  the  long  axis  of  the 
tooth  and  the  plugger  held  parallel  with  this  axis.  When  a  blow 
is  struck  in  this  direction  the  force  is  distributed  throughout  the 
entire  surface  of  the  membrane  instead  of  being  exerted  against 
only  one  side  of  the  root,  as  would  result  if  a  blow  were  struck  at 
right  angles  to  any  of  the  axial  surfaces.  There  are,  of  course, 
instances  where  lateral  force  must  be  employed,  but  these  are 
usually  in  fillings  of  limited  area  where  the  aggregate  mallet  force 
is  not  sufficient  to  leave  any  serious  impress  upon  the  membrane. 


CHAPTER   IX 

THE  INTRODUCTION,  CONDENSATION,  AND 

FINISHING  OF  GOLD  FILLINGS  IN 

THE  DIFFERENT  CLASSES 

OF  CAVITIES 

While  each  cavity  is  to  a  certain  degree  a  law  unto  itself  so  far 
as  the  manner  of  building  the  filling  is  concerned,  yet  there  are 
fundamental  principles  of  procedure  which  if  intelligently  recog- 
nized will  render  the  work  more  systematic  and  satisfactory.  The 
methods  herein  suggested  are  not  always  applicable  because  of  the 
constant  occurrence  of  cavities  unique  in  location  and  form,  but 
for  the  so-called  typical  cavities  of  the  different  classes  it  is  be- 
lieved that  if  intelligently  followed  they  will  at  least  prove  ef- 
fective in  the  accomplishment  of  satisfactory  work. 

The  arrangement  in  the  cavity  of  the  layers  of  foil  constituting 
a  pellet  becomes  a  matter  of  some  importance  in  its  relation  to 
the  symmetrical  growth  of  the  filling  under  the  plugger,  and  also 
to  its  resultant  strength.  It  is  with  this  idea  in  mind  that  the 
present  plans  of  procedure  have  been  suggested,  as  well  as  on  the 
basis  of  expediency  in  the  manner  of  building  the  filling. 

To  start  any  filling  a  rope  of  non-cohesive  gold,  varying  in  size 
as  indicated  by  the  requirements  of  the  case,  will  be  found  ef- 
fective. A  convenient  form  may  be  made  as  follows:  Divide  a 
sheet  of  No.  4  foil  once,  making  one-half  of  a  sheet;  then  roll  into 
a  rope  about  the  size  of  a  large  knitting  needle,  and  cut  the  rope  in 
three  parts.  This  makes  a  rope  approximately  an  inch  in  length, 
and  of  a  size  that  can  be  readily  carried  into  most  cavities  of  any 
extent.  In  small  cavities  the  rope  may  be  cut  short  enough  for 
convenience,  while  in  cavities  of  very  large  area  it  will  be  found 
desirable  to  roll  the  rope  from  an  entire  sheet  of  foil  and  cut  to 
suitable  lengths. 

When  starting  a  filling  the  rope  should  be  grasped  by  the  pliers 
about  one-fourth  of  an  inch  from  the  end,  and  this  end  carried  into 
the  angle  of  the  cavity  where  it  is  intended  to  commence  the  filling. 
The  rope  will  fold  upon  itself  as  it  is  pressed  into  the  angle,  so  that 

174 


INTRODUCTION   AND    FINISHING    OF   GOLD    FILLINGS  175 

it  will  remain  there  while  the  pliers  release  it  and  grasp  it  farther 
back  and  fold  it  once  more  into  the  cavity.  This  process  is  kept 
up  till  the  entire  rope  is  carried  into  position,  where  it  may  be  con- 
densed-in  the  manner  to  be  described  when  considering  the  details 
of  filling-building  in  the  different  cavities.  Into  the  structure  of 
this  non-cohesive  cushion  may  be  wedged  the  first  pellets  of  co- 
hesive gold  till  the  two  forms  of  gold  are  so  interlocked  that  they 
will  not  separate,  when  the  filling  may  be  completed  with  cohesive 
gold. 

Simple  Proximal  Fillings  in  Incisors 

These  fillings,  when  built  from  the  labial  aspect,  are  ordinarily 
best  started  in  the  gingivo-linguo-axial  angle  of  the  cavity  by  carry- 
ing a  rope  of  non-cohesive  gold  into  this  angle  as  already  indi- 
cated. The  rope  should  be  folded  upon  itself  from  the  starting 
point  along  the  gingival  wall  toward  the  labial  wall,  till  it  is  se- 
curely locked  between  the  gingival  third  of  the  labial  and  lin- 
gual walls.  If  the  gingival  wall  has  been  made  fiat  there  will  be 
little  difficulty  in  securing  the  rope  in  place.  The  first  rope  used 
should  be  of  sufficient  size  to  cover  the  entire  gingival  wall  from 
lingual  to  labial,  and  extend  well  over  the  gingival  enamel- 
margin.  The  office  of  this  rope  is  to  secure  ready  adaptation  to 
the  angles  of  the  cavity,  and  also  to  form  a  non-cohesive  cushion 
against  which  cohesive  gold  may  be  condensed  without  danger 
of  injury  to  the  gingival  enamel-margin.  In  condensing  gold 
over  margins  it  should  always  be  a  cardinal  principle  to  keep  a 
sufficient  mat  of  gold  between  the  plugger  point  and  the  margin 
to  avoid  the  possibility  of  injuring  the  enamel  with  the  serrations 
of  the  plugger. 

When  the  non-cohesive  rope  has  been  carried  to  place  with  the 
pliers  it  should  be  more  securely  locked  in  position  by  bringing  a 
plugger  to  bear  on  it  at  two  or  three  points  with  hand  pressure, 
wielded  in  the  rocking  motion  already  described.  The  first  direc- 
tion of  the  plugger  should  be  toward  the  gingivo-linguo-axial 
angle,  and  the  gold  should  be  wedged  into  this  angle  with  con- 
siderable force.  If  the  rocking  motion  of  the  plugger  is  used  the 
gold  can  be  so  locked  into  place  as  not  to  be  readily  moved  by 
subsequent  manipulation,  but  if  there  seems  any  doubt  about  its 
security  a  retaining  instrument  may  be  placed  on  the  condensed 
gold  the  moment  the  plugger  is  withdrawn,  and  held  there  while 
the  locking  process  is  carried  on  by  the  plugger  at  other  points. 


176  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

The  next  direction  of  the  plugger  should  be  toward  the  gingivo- 
labio-axial  angle,  and  these  two  points  may  be  all  that  is  necessary 
to  condense  at  this  time.  The  object  is  simply  to  lock  the  rope 
into  the  angles  of  the  cavity  rather  than  to  attempt  the  conden- 
sation of  the  entire  mass.  In  fact,  too  much  condensation  must 
be  avoided  until  some  cohesive  gold  has  been  called  into  service. 
After  the  plugger  is  withdrawn  from  the  gingivo-labial  angle  a 
cohesive  cylinder  sufficiently  large  to  cover  the  entire  gingivo- 
lingual  region  should  be  laid  with  its  side  upon  the  non-cohesive 
gold  and  one  end  looking  along  the  lingual  wall  and  the  other 
along  the  gingival  wall.  This  should  then  be  forced  into  the 
substance  of  the  non-cohesive  gold  in  the  direction  of  the  gingivo- 
linguo-axial  angle,  so  as  to  incorporate  the  two  forms  of  gold  into 
one  mass.  After  pinning  this  pellet  of  cohesive  gold  into  the  non- 
cohesive  at  several  points  with  hand  pressure,  another  cylinder 
of  cohesive  gold  may  be  forced  into  the  gingivo-labio-axial  angle 
in  the  same  manner.  These  two  pellets  will  usually  reach  across 
the  entire  gingival  wall,  but  if  they  do  not  a  third  one  may  be 
used  to  connect  the  two.  When  there  is  a  complete  covering  of 
cohesive  gold  over  the  non-cohesive  the  mallet  may  be  used  for 
the  first  time,  and  the  entire  mass  malleted  to  place.  The  result 
is  that  the  gingival  wall  is  perfectly  protected  by  a  cushion  of  non- 
cohesive  gold  covered  by  a  layer  of  cohesive  gold,  and  the  whole 
locked  between  the  labial  and  hngual  walls  of  the  cavity  with  a 
slight  excess  of  gold  overlying  the  gingival  enamel-margin  to  in- 
sure sufficient  material  for  a  perfect  finish. 

In  building  the  filling  from  this  point  the  pellets  of  cohesive 
gold  should  be  laid  with  their  sides  looking  toward  the  gingival 
wall  and  their  ends  looking  labially  and  lingually,  and  each  pellet 
should  be  wide  enough  to  reach  from  the  axial  wall  to  the  extreme 
proximal  surface  of  the  filHng.  With  this  arrangement  of  the 
pellets  the  condensation  is  in  the  direction  of  the  long  axis  of  the 
tooth,  and  the  filling  is  kept  sufficiently  prominent  on  its  proximal 
surface  while  it  is  being  built  down  to  avoid  the  necessity  of  subse- 
quently adding  any  gold  laterally  to  this  surface  to  round  out  the 
filling.  Gold  tacked  on  the  proximal  surface  of  one  of  these 
fillings  by  laying  the  pellet  on  its  side  and  directing  the  mallet 
force  at  right  angles  with  the  long  axis  of  the  tooth  is  not  so  se- 
curely maintained  in  place  as  it  is  where  the  arrangement  of  the 
gold  is  such  that  each  pellet  reaches  from  the  proximal  surface  to 
the  axial  wall  and  is  built  toward  the  gingival  wall.     The  operator 


INTRODUCTION  AND   FINISHING   OF   GOLD   FILLINGS  177 

cannot  always  avoid  the  necessity  of  arranging  his  gold  so  that 
the  condensation  is  in  the  direction  of  the  axial  wall,  but  this  ne- 
cessity is  usually  confined  to  small  fillings  where  the  means  of 
approach  will  not  permit  of  any  other  arrangement,  and  where 
the  element  of  strength  is  not  so  material. 

One  important  consideration  in  building  these  fillings  relates 
to  the  protection  of  the  lingual  margin.  This  seems  to  be  the 
most  difficult  feature  in  their  insertion,  and  it  is  where  operators 
fail  more  often  than  at  any  other  point.  This  failure  is  usually 
due  to  inadequate  covering  of  the  margin  as  the  gold  is  being 
built  along  the  lingual  wall  toward  the  incisal  angle.  A  shght 
excess  of  gold  should  invariably  be  carried  over  this  margin,  and 
in  order  to  be  assured  of  this  the  operator  should  keep  the  gold  in 
the  hngual  region  built  somewhat  in  advance  of  the  filling  at  the 
labial  margin.  That  is,  the  gold  should  extend  farther  incisally 
along  the  lingual  than  along  the  labial  wall,  so  that  the  operator 
may  clearly  see  the  lingual  margin  and  thus  be  certain  of  lapping 
the  gold  over  it.  If  the  labial  part  of  the  filling  be  built  in  the 
least  advance  of  the  other,  it  obstructs  the  view  of  the  lingjial 
margin  and  prevents  access  with  the  plugger. 

As  the  fining  is  being  built  down  toward  the  incisal  angle,  the 
operator  must  have  a  care  not  to  approach  too  near  the  angle  be- 
fore wedging  some  gold  into  the  angle  and  between  it  and  the 
filling  aheady  in  place.  If  the  cavity  is  deep  pulpally,  so  as  to 
leave  an  appreciable  pocket  between  the  condensed  gold  and  the 
incisal  angle  of  the  cavity,  it  is  advisable  to  use  a  short  rope  or 
cylinder  of  non-cohesive  gold  to  wedge  into  this  pocket  to  be  as- 
sured of  perfect  adaptation.  Into  this  non-cohesive  gold  a  small 
pellet  of  cohesive  gold  may  be  forced  with  hand  pressure,  and  the 
filling  completed  with  the  mallet. 

When  a  filHng  is  thus  inserted  it  will  be  fouhd  that  there  is  a 
slight  excess  of  gold  overlapping  the  margins  of  the  cavity,  and  the 
final  step  in  condensing  such  a  filling  should  be  to  mallet  down 
this  gold  with  a  foot  plugger.  If  access  cannot  be  gained  with  a 
plugger  a  very  thin  burnisher  may  be  used  to  force  the  gold  to 
place,  burnishing  from  the  center  of  the  filling  toward  and  over 
the  margins.     Then  the  filling  is  ready  for  pohshing. 

In  cavities  where  the  Ungual  wall  is  missing  and  the  labial  wall 
perfect,  so  that  the  filling  must  be  built  from  the  lingual  aspect, 
the  s^me  general  principles  of  filling-building  may  be  followed, 
except  that  the  gold  should  be  started  in  the  gingivo-labial  region 


178  PEINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

instead  of  the  gingivo-lingual,  and  the  filHng  kept  more  prominent 
along  the  labial  wall  as  it  approaches  the  incisal  angle.  The  same 
care  must  be  exercised  in  lapping  an  excess  of  gold  over  the  labial 
margin  while  the  filling  is  being  built  that  was  advised  for  the 
lingual  margin  while  building  from  the  labial  aspect.  It  is  well- 
nigh  impossible  to  tack  gold  on  the  labial  region  of  the  filling  after 
it  has  been  built  down  to  the  incisal  angle,  and  the  operator  should 
therefore  provide  perfect  protection  to  this  wall  while  he  has  the 
opportunity. 

In  those  cases  with  the  lingual  wall  missing  but  the  labial  aspect 
so  open  that  the  filling  must  be  built  mostly  from  this  direction, 
the  gold  should  be  started  in  the  regular  way,  and  as  the  lingual 
margin  is  being  covered  a  portion  of  each  pellet  should  be  allowed 
to  extend  some  distance  over  the  margin  and  hang  beyond  the 
lingual  surface  of  the  tooth.  This  end  of  the  pellet  cannot  be  con- 
densed from  the  labial  aspect,  but  the  portion  reaching  into  the 
cavity  can  be  made  fast  to  the  filling  and  the  filling  built  as  full 
as  convenient  from  this  aspect.  When  the  labio-proximal  portion 
of  the  filling  is  built  to  form  it  will  be  found  that  from  the  lingual 
aspect  a  large  mass  of  uncondensed  gold  extends  lingually  beyond 
the  margin,  each  pellet  of  which  is  securely  fastened  into  the 
substance  of  the  condensed  portion  of  the  filling.  This  uncon- 
densed mass  will  ordinarily  not  contain  sufficient  gold  to  properly 
round  out  the  filling  when  malleted  to  place  without  the  addition 
of  more  gold,  and  it  is  the  addition  of  this  gold  from  the  lingual 
aspect  which  often  proves  troublesome  to  operators.  To  avoid 
difficulty  of  this  nature  it  is  suggested  to  take  an  annealed  pellet 
and  force  it  with  hand  pressure  up  into  the  structure  of  the  uncon- 
densed gold  before  malleting  the  latter  to  place.  If  this  be  done 
the  freshly  annealed  pellet  will  leave  a  surface  to  which,  if  neces- 
sary, more  gold  may  be  attached  with  greater  certainty  than 
where  the  uncondensed  gold  has  been  malleted  without  this 
precaution. 

The  object  of  leaving  this  excess  of  uncondensed  gold  is  to 
enable  the  operator  to  interweave  the  freshly  annealed  pellets  into 
its  substance,  and  thus  prevent  flaking  of  the  lingual  portion  of 
the  filling,  which  is  likely  to  occur  where  an  attempt  is  made  to 
condense  the  gold  as  the  filling  is  being  built  down,  and  then  add 
more  gold  to  the  condensed  surface  from  the  lingual  aspect. 
Wherever  possible  the  practice  should  be  avoided  of  leaving  for 
any  length  of  time  a  condensed  surface  of  gold  exposed  to  the 


INTRODUCTION   AND    FINISHING    OF    GOLD    FILLINGS 


179 


atmosphere  with  the  expectation  of  subsequently  adding  more 
gold  to  it.  The  property  of  cohesion  seems  to  be  more  or  less 
impaired  by  exposure,  and  in  order  to  secure  the  best  working 
quality  to  cohesive  gold  it  will  be  found  desirable  to  add  pellet  after 
pellet  to  the  freshly  condensed  surfaces  from  beginning  to  com- 
pletion of  the  operation. 

Pluggers 

The  choice  of  pluggers  becomes  largely  a  matter  of  personal 
selection  with  most  operators,  but  for  these  proximal  fillings  in 
anterior  teeth  the  forms  here  illustrated  would  seem  to  answer  a 
convenient  purpose.     Fig.  95  is  suggested  for  starting  the  filling 


Fig.  95. 


I 
Fig.  96. 


Fig.  97. 


Fig.  98. 


Fig.  99. 


Fig.   100. 


and  locking  the  gold  into  the  gingival  third  of  the  cavity.  Its 
length  from  the  serrated  end  to  the  angle  is  sufficient  to  reach 
perfectly  to  the  gingival  region  of  any  cavity  in  an  incisor,  and  the 
degree  of  .curve  is  such  that  direct  hand  pressure  or  mallet  force 
may  be  exerted  against  the  gingival  wall.  In  cavities  of  large 
area  with  ready  access  much  of  the  filling  may  be  built  with  it  to 
the  point  where  the  incisal  angle  requires  protection,  but  for 
small  cavities  other  forms  are  mostly  indicated. 

As  the  incisal  angle  is  reached  a  plugger  of  smaller  size,  and 
with  a  greater  curve,  is  required,  such  as  the  pair,  right  and  left, 
illustrated  in  Fig.  96.  Occasionally  even  these  forms  will  not 
properly  reach  the  angle  on  account  of  the  position  of  the  proxi- 
mating  tooth,  and  where  such  is  the  case  a  small,  short  right-angle 
plugger  is  indicated  (Fig.  97).  These  right-angle  pluggers  are 
invariably  to  be  used  with  hand  pressure,  and  in  cases  difficult  of 


180  PRINCIPLES    AND    PRACTICE    OF   FILLING    TEETH 

access  the  gold  may  often  be  "tucked  up  "  into  an  angle  in  this  way 
when  mallet  force  is  entirely  impracticable. 

For  building  fillings  from  the  lingual  aspect  in  all  cavities  of 
sufficient  size  Fig.  95  is  especially  adapted,  on  account  of  its 
adequate  reach.  In  cavities  too  limited  for  its  use,  whether  of 
labial  or  lingual  aspect,  the  form  illustrated  in  Fig.  98  may  be  sub- 
stituted to  advantage  in  conjunction  with  the  curved  pair  (Fig. 
96). 

One  important  factor  in  securing  the  most  stable  anchorage  of 
these  fillings  relates  to  perfect  density  of  the  gold  along  the  angles 
which  join  the  walls  of  the  cavity.  As  has  previously  been  stated, 
accurate  adaptation  of  gold  may  be  obtained  to  any  angle  pro- 
vided the  proper  form  of  plugger  point  is  used,  and  for  this  purpose 
such  a  form  as  that  in  Fig.  99  is  excellent  in  those  positions  where 
it  will  approach.  Another  form  suggested  for  places  where  Fig. 
99  will  not  reach,  and  especially  for  curving  under  the  labial  wall 
and  carrying  the  gold  into  the  angle  between  the  labial  and  axial 
walls,  is  shown  in  Fig.  100.  In  cavities  where  these  forms  are  not 
available  for  the  angles  the  curved  pluggers  with  round  points  may 
be  made  to  do  good  service,  and  secure  perfect  adaptation  by 
exercising  care  and  malleting  step  by  step  along  the  angle  so  that 
the  plugger  point  covers'  the  entire  mass  of  gold  with  the  mallet 
impact.  For  the  surface  of  these  fillings,  according  to  their  area, 
pluggers  ranging  from  Fig.  99  up  to  a  small-sized  foot  plugger 
may  be  used  to  give  an  even,  dense  surface. 

Finishir.g  Proximal  Fillings  in  Incisors 

When  the  filling  is  built  to  proper  form  the  gold  will  ordinarily 
be  found  to  knuckle  tightly  against  the  contact  point  of  the  proxi- 
mating  tooth,  and  in  finishing  the  filling  the  operator  must  avoid 
cutting  away  the  gold  at  this  point,  and  thus  producing  a  flat 
proximal  surface  to  the  filling.  The  gold  should  be  left  rounded 
out  to  a  contact  point,  the  same  as  was  on  the  tooth  originally 
before  decay  began.  To  this  end  a  narrow  finishing  strip  should 
be  used  in  the  interproximal  space  to  dress  the  gingival  third  of  the 
filling  to  form,  and  this  part  of  the  filling  should  be  finished  even 
with  the  surface  of  the  tooth  before  any  attempt  is  made  to  trini 
the  filling  at  other  points.  The  strip  should  not  be  so  wide  that  in 
drawing  it  back  and  forth  between  the  teeth  it  will  reach  to  the 
contact  point  and  cut  it  down.     If  the  filling  is  so  snug  against  the 


INTRODUCTION   AND    I^NISHING    OF   GOLD    FILLINGS  181 

proximating  tooth  that  the  strip  cannot  be  carried  between  the 
teeth,  it  may  be  introduced  endwise  into  the  interproximal 
space  from  the  labial  aspect. 

When  the  gingival  margin  is  properly  trimmed  to  form,  the 
gingivo-lingual  portion  of  the  filling  may  often  be  dressed  down  by 
carrying  the  cutting  surface  of  the  strip — which  is  still  in  the  inter- 
proximal space — as  nearly  as  possible  along  the  lingual  surface  of 
the  tooth,  and  the  back  or  smooth  side  of  the  strip  across  the  la- 
bial surface  of  the  proximating  tooth.  This  brings  pressure  of  the 
cutting  side  of  the  strip  to  bear  immediately  on  the  gingivo- 
lingual  part  of  the  filling,  and  it  does  not  cut  at  any  other  point. 

After  the  narrow  strip  has  been  used  it  will  often  be  found  con- 
venient to  slip  on  a  separator  where  one  has  not  previously  been 
employed,  and  force  the  teeth  slightly  apart  to  admit  of  a  finishing 
strip  being  carried  between  the  teeth.  Where  this  cannot  be 
done  a  very  thin,  broad  burnisher,  battered  out  to  a  uniform 
thickness  and  having  a  sharp  edge,  after  the  nature  of  the 
Dunn  hand  matrix,  or  the  gum  depressor  (Fig.  31)  should 
be  forced  between  the  filling  and  the  proximating  tooth,  and 
the  end  of  the  handle  swung  back  and  forth,  describing  the 
arc  of  a  circle,  while  the  blade  is  held  between  the  teeth  till  there  is 
more  or  less  freedom  of  movement  of  the  burnisher.  This  will 
ordinarily  smooth  the  gold  so  that  a  strip  may  be  passed  between 
the  teeth. 

The  strip  used  for  finishing  this  portion  of  the  filling  should  be- 
broad,  and  in  manipulating  it  the  cutting  surface  should  be  drawn 
quite  sharply  across  the  labial  and  lingual  surfaces  of  the  tooth,  so- 
that  the  filling  will  be  rounded  and  the  labial  and  lingual  aspects 
dressed  even  with  the  cavity-margins.  In  those  cases  where  the 
hngual  surface  of  the  tooth  is  so  concave  that  the  strips  will  not 
follow  the  outline  of  the  cavity,  a  sand-paper  disk  in  the  engine 
may  be  used  to  dress  this  portion  of  the  filling  to  form  by  directing 
the  disk  into  the  concavity  with  a  round-headed  burnisher. 

After  the  filling  is  of  the  proper  form  it  may  be  polished  with  a 
finishing  strip  of  the  finest  grit,  or  thin  linen  tape  may  be  used, 
carrying  with  it  fine  silex,  followed  by  whiting.  All  of  this 
should  be  done  before  the  removal  of  the  rubber  dam,  on  account 
of  the  protection  afforded  by  the  dam  to  the  gums  and  lips,  and 
also  because  the  saliva  interferes  with  the  work. 

Whenever  strips  or  disks  are  used  in  finishing  gold  fillings  they 
should  invariably  be  smeared  with  vaseline,  oil,  or  some  similar 


182  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

lubricant  to  avoid  as  much  as  may  be  the  generation  of  heat  in  the 
filhng.  The  lubricant  also  renders  the  disk  pliable,  and  it  can 
therefore  be  directed  into  depressions  with  a  round-headed  instru- 
ment— such  as  a  ball  burnisher — to  much  better  advantage  than 
where  such  an  attempt  is  made  with  a  dry  disk.  This  practice  will 
also  prove  of  considerable  financial  advantage  to  the  dentist  if  he 
will  preserve  his  worn-out  disks  and  strips  and  send  them  to  the 
refiner.  The  amount  of  gold  retained  on  the  sanded  surface,  if 
lubricated  this  way,  will  in  the  aggregate  yield  a  surprising  profit 
in  the  course  of  a  year,  and  no  operator  should  ignore  this  kind  of 
economy. 

Another  aid  in  the  maintenance  of  a  normal  temperature  in  a 
filling  under  the  friction  of  a  strip  or  disk  may  be  made  available 
by  those  who  have  compressed  air  at  their  command.  If  a  jet  of 
air  be  allowed  to  play  upon  the  filling  during  the  process  of  polish- 
ing, it  will  be  found  to  equalize  the  temperature  and  render  the 
work  more  tolerable  to  the  patient. 

Proximal  Fillings  in  Anterior  Teeth  Involving  the  Incisal  Angle 

The  method  of  building  these  fillings  is  practically  the  same  as 
that  for  simple  proximal  fillings  down  to  the  point  where  the 
incisal  anchorage  is  made,  except  that  in  the  contour  fillings  the 
open  aspect  of  the  cavity  renders  it  possible  to  more  uniformly  lay 
the  gold  on  parallel  with  the  gingival  wall  and  at  right  angles  to 
the  stress  of  mastication.  In  these  large  fillings  the  proximal  sur- 
face should  be  kept  sufficiently  prominent  as  the  filHng  is  being 
built  from  the  gingival  to  the  incisal  region,  to  make  it  unnec- 
essary to  add  more  gold  laterally  to  the  proximal  surface  to 
complete  its  contour. 

In  those  cases  where  the  incisal  anchorage  has  been  made  be- 
tween the  two  plates  of  enamel  in  the  incisal  third  of  the  axial  wall, 
the  greatest  care  must  be  exercised  in  securing  perfect  adaptation 
and  density  of  the  gold  in  this  anchorage.  Small  pieces  of  gold 
must  be  used,  and  each  piece  compactly  malleted  to  place  with 
small  pluggers.  The  slightest  lack  of  density  or  the  slightest 
bridging  of  the  gold  at  this  point  must  eventually  result  in  a 
springing  away  of  the  incisal  portion  of  the  filling  which  sooner 
or  later  leads  to  its  loss. 

Where  the  incisal  anchorage  is  made  by  cutting  a  step  or  groove 
across  the  end  of  the  tooth  at  right  angles  to  the  proximal  cavity,  as 


INTRODUCTION   AND    FINISHING   OF   GOLD    FILLINGS  183 

suggested  in  considering  cavity  preparation,  the  method  of  build- 
ing the  fining  is  to  carry  the  gold  down  the  proximal  portion  of 
the  cavity  level  with  the  base  of  the  step  in  the  ordinary  way,  and 
then  lay  a  pellet  with  its  side  presented  to  the  floor  of  the  step  and 
its  ends  looking  mesially  and  distally,  reaching  from  the  center  of 
the  gold  already  condensed  over  into  the  step.  The  pellet  should 
be  fastened  securely  to  the  condensed  gold,  and  then  malleted  to 
place  in  the  step.  Another  pellet  should  be  laid  slightly  farther 
along  the  step,  but  with  one  end  still  lapping  the  gold  already  in 
place.  In  this  way  the  proximal  portion  of  the  filling  is  securely 
locked  into  the  step,  and  the  greatest  possible  strength  is  given  the 
gold  at  the  point  where  the  proximal  joins  the  incisal  portion  of 
the  filling  by  such  an  arrangement  of  the  pellets.  This  process 
of  building  the  gold  should  be  carried  on  till  the  end  of  the  step 
is  reached.  The  entire  incisal  portion  of  the  filling  must  be  built 
up  with  the  greatest  care,  and  the  arrangement  of  the  pellets,  so 
far  as  possible,  should  be  in  the  order  already  suggested — the  sides 
at  right  angles  to  the  force  of  occlusion,  and  the  ends  looking 
mesially  and  distally  across  the  step. 

The  gold  should  be  perfectly  annealed  and  small  pellets  em- 
ployed, to  the  end  that  the  greatest  degree  of  density  and  resisting 
power  is  imparted  to  the  gold.  For  this  portion  of  the  filling  it  is 
sometimes  desirable  to  use  the  heavier  gold  in  strips,  such  as  the 
No.  60;  or  in  cases  where  extreme  density  is  required  platinum- 
and-gold  may  be  employed.  If  the  heavy  gold  is  used  it  should 
not  be  added  till  the  surface  is  nearly  reached,  on  account  of  the 
greater  difficulty  of  securing  perfect  adaptation  to  the  labial  plate 
of  enamel. 

This  is  one  of  the  most  important  considerations  in  building 
these  fillings.  Unless  the  gold  is  adapted  to  the  labial  plate  with 
the  greatest  accuracy  there  will  eventually  occur  a  leak  at  this 
point,  which  will  result  in  such  discoloration  as  to  make  the  tooth 
unsightly.  The  angle  between  the  labial  plate  and  the  step 
should  also  receive  close  attention  in  adapting  the  gold,  so  that 
the  filling  may  be  securely  seated  in  place. 

For  building  this  portion  of  the  filling  pluggers  99  and  100  are 
admirably  adapted,  though  larger  sizes  may  be  used  in  cases 
where  the  area  of  the  cavity  will  permit  it.  In  teeth  long  and 
thin,  where  the  step  must  be  correspondingly  deep  and  narrow 
and  where  it  has  been  made  to  terminate  in  a  depression,  for  the 
more  secure  anchorage  of  the  filling  a  plugger  as  small  as  Fig.  98 


184  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

may  be  required  to  reach  the  deepest  part  of  the  step  and  bring 
this  portion  of  the  filhng  level  with  the  rest;  but  when  this  is 
accomplished  Figs.  99  and  100  will  ordinarily  be  found  none  too 
large  to  complete  the  operation.  As  the  surface  of  the  filling  is 
reached  the  gold  should  be  malleted  somewhat  beyond  the  stage 
where  it  seems  dense,  on  the  theory  that  repeated  blows  harden 
gold  and  make  it  more  resistant,  even  after  compactness  has  been 
reached.  In  going  over  the  surface  for  the  last  time  with  the 
mallet  a  smooth-faced  plugger  may  be  used,  and  the  blows  so 
arranged  that  the  final  ones  are  invariably  struck  along  the 
margins. 

For  finishing  the  incisal  aspect  of  these  fillings  a  sand-paper 
disk,  held  to  position  with  a  ball  burnisher,  will  quickly  dress  the 
filling  to  form,  after  which  it  may  be  polished  with  a  fine  cuttle- 
fish disk. 

Fillings  in  Proximo -Occlusal  Cavities  in  Bicuspids  and  Molars 

In  view  of  the  fact  that  most  of  these  cavities  may  be  more 
acceptably  managed  with  gold  inlays  than  with  foil  fillings,  it  is 
deemed  necessary  to  consider  only  in  brief  the  insertion  of  foil. 
The  reason  that  inlays  have  practically  displaced  foil  in  these 
cases  relates  chiefly  to  two  considerations;  the  fact  that  patients, 
will  no  longer  tolerate  sittings  sufficiently  long  to  insert  large  foil 
fillings  when  there  is  an  acceptable  method  whereby  this  may  be 
avoided,  and  also  because  in  many  of  these  remote  cavities  it  is 
possible  to  obtain  a  better  technique  with  inlays  than  with  foil. 
In  all  cavities  in  the  teeth  that  method  should  be  used  by  which 
the  best  results  may  be  obtained,  and  with  the  majority  of 
operators  this  is  more  readily  accomplished  with  inlays  in  these 
cases,  and  with  less  tension  on  patient  and  dentist  than  with 
foil  fillings.  One  important  consideration  in  this  connection 
relates  to  the  contact  point.  The  significance  of  this  has  already 
been  referred  to  in  some  detail,  and  the  necessity  of  obtaining 
a  small  rounded  contact  on  our  proximal  fillings  has  been  empha- 
sized. This  can  be  accomplished  with  much  greater  ease  and 
certainty  on  inlays  than  on  foil  fillings,  and  this  fact  furnishes 
a  very  strong  argument  in  favor  of  inlays  over  fillings  in  these 
cavities. 

But  every  practitioner  should  be  familiar  with  the  insertion  of 
foil  in  all  classes  of  cavities,  and  to  this  end  the  following  brief 
technique  is  suggested. 


INTRODUCTION   AND    FINISHING    OF   GOLD    FILLINGS 


185 


These  fillings  should  be  started  with  non-cohesive  foil  in  every 
instance,  beginning  usually  in  the  gingivo-lingual  angle  and 
building  the  non-cohesive  gold  over  the  entire  gingival  wall  and 
at  least  one-third  the  way  to  the  occlusal  step.  The  non- 
cohesive  gold  is  best  carried  to  place  with  hand  pressure  with 
plugger  points  sufficiently  large  in  area  to  cover  the  gingival 
wall  mesio-distally,  such  as  that  illustrated  in  Fig.  101.  Then 
when  the  non-cohesive  gold  is  seated  in  this  way  the  first  pellet 
of  cohesive  gold  is  wedged  with  a  smaller  plugger,  such  as  Fig. 
95,  102,  or  103,  into  the  structure  of  the  non-cohesive  gold  at 
either  the  lingual  or  buccal  wall  and  tightened  with  a  heavy  soft 


Fig.   101.    Fig.   102.     Fig.   10.3.     Fig.   104. 


mallet  into  the  angle  between  the  wall  and  the  non-cohesive 
gold.  Cohesive  pellets  are  then  built  along  over  the  non- 
cohesive  gold  toward  the  opposite  wall  of  the  cavity  till  a  layer 
of  cohesive  gold  extends  from  the  buccal  to  the  lingual  wall  and 
overlies  the  non-cohesive  cushion  of  gold  in  the  gingival  region. 
Over  this  whole  mass  the  heavy  soft  mallet  should  be  used  to 
gain  greater  density  not  only  to  the  cohesive  gold  but  through 
this  to  the  non-cohesive  gold  beneath  it.  In  building  this  part 
of  the  filling  the  cylinders  or  pellets  should  be  laid  on  their  side 
with  the  ends  looking  buccally  and  lingually,  but  when  the  floor 
of  the  step  is  reached  the  direction  of  the  cylinders  should  be 
changed  so  that  the  ends  look  mesially  and  distally.  This 
arrangement  locks  the  proximal  portion  of  the  filling  securely 
into  the  step  portion,  and  makes  the  strongest  possible  filling.  As 
the  gold  reaches  the  contact  point  great  care  should  be  exercised 


186  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

to  gain  the  highest  possible  density  and  hardness  to  the  gold  at 
this  point  by  playing  the  mallet  over  it  sometime  after  con- 
densation is  complete.  This  may  best  be  done  with  a  hard  steel 
mallet. 

The  last  layers  of  foil  on  the  occlusal  surfaces  should  be  laid 
on  with  much  care,  and  condensed  very  thoroughly,  in  order 
to  secure  the  best  possible  wearing  surface.  As  the  filling  ap- 
proaches completion  the  plugger  point  should  be  smaller  and 
straighter  and  the  blows  should  be  struck  with  the  plugger 
stepping  constantly  from  the  center  of  the  filling  toward  the 
margin  to  the  end  that  the  gold  is  thus  tightened  against  the 
walls,  such  as  Figs.  98  or  99.  During  the  process  of  building  the 
filling  if  any  locations  arise  where  it  is  difficult  to  exert  direct 
mallet  impact  against  a  wall,  a  curved  plugger,  such  as  Fig.  104, 
should  be  used  with  hand  pressure  to  pull  the  gold  firmly  against 
the  wall.  Adaptation  is  one  of  the  chief  considerations  in  the 
insertion  of  these  fillings  and  this  is  quite  likely  to  be  overlooked 
in  those  parts  of  the  cavity  which  stand  nearest  the  operator, 
and  where  the  wall  looks  away  from  him  and  cannot  be  seen 
except  with  a  mirror.  Unless  hand  pressure  is  used  in  these 
regions  the  gold  will  be  bridged  over,  leaving  a  space  for  leakage 
along  the  wall. 

Finishing  the  Filling 

When  the  insertion  of  the  gold  is  completed  a  thin  burnisher 
should  be  used  to  go  along  the  margins  and  press  down  the  slight 
excess  of  gold  over  the  enamel,  after  which  a  narrow  finishing 
strip  may  be  passed  into  the  interproximal  space  and  the  gingival 
portion  of  the  filling  dressed  even  with  the  surface  of  the  tooth. 
On  account  of  the  close  contact,  it  will  ordinarily  be  found 
impossible  to  force  this  strip  between  the  teeth  from  the  occlusal 
aspect,  in  event  of  which  it  may  be  passed  end-foremost  into  the 
space  from  the  buccal  aspect.  The  strips  used  should  be  narrow 
enough  to  play  back  and  forth  in  the  space  without  danger  of 
dressing  down  the  contact  point. 

When  the  gingival  portion  of  the  filling  is  perfectly  finished,  a 
sand-paper  disk  may  be  used  in  the  engine  to  play  along  the 
buccal  and  lingual  margins  as  they  approach  the  occlusal  surface 
and  dress  the  filling  even  with  the  surface  of  the  tooth,  but  the 
disk  should  not.be  allowed  to  pass  between  the  teeth,  through 
danger  of  cutting  down  the  contact  point  and  creating  a  flat 


INTRODUCTION    AND    FINISHING    OF   GOLD    FILLINGS  187 

surface.  The  disk  may  also  be  used  to  advantage  to  smooth  that 
portion  of  the  occlusal  surface  of  the  filling  which  slopes  from  the 
contact  point  up  toward  the  cusps,  by  tipping  the  disk  slightly 
and  forcing  it  into  position  with  a  ball  burnisher. 

To  polish  the  proximal  surface  of  the  filling  immediately  at 
the  contact  point  a  broad,  fine  finishing  strip  should  be  used, 
merely  with  the  object  of  smoothing  the  gold,  and  rounding  the 
contact  point,  without  cutting  it  away.  If  the  filling  is  so  tight 
against  the  proximating  tooth  that  even  a  thin  strip  cannot  be 
passed  between  the  teeth,  a  separator  may  be  employed  to  gain 
the  slight  space  necessary,  or,  if  this  is  not  practicable,  the  broad, 
thin  burnisher  previously  mentioned  in  connection  with  the  finish- 
ing of  proximal  fillings  in  incisors  may  be  forced  between  the 
teeth  and  manipulated  with  a  rotating  motion  till  the  gold  is 
burnished  smooth  and  the  way  cleared  for  the  introduction  of  the 
polishing  strip.  This  broad  burnisher  will  be  found  very  service- 
able in  all  these  contour  fillings  where  contact  is  close,  and  it 
should  be  in  the  hands  of  every  operator. 

When  the  proximal  surface  of  the  filling  is  thus  dressed  to 
form  and  polished,  the  rubber  dam  should  at  once  be  removed 
and  the  occlusal  surface  ground  to  form  with  carborundum  stones 
kept  moist.  The  patient  should  be  instructed  to  close  the  jaws 
frequently  to  test  the  necessary  fullness  to  which  the  filling  may 
be  left  without  interfering  with  the  occlusion,  and  in  the  event  of 
a  sharp  cusp  from  the  opposing  tooth  striking  so  far  into  the  filling 
as  to  necessitate  grinding  it  too  thin,  it  is  always  advisable  to 
shorten  the  cusp  of  the  opposing  tooth  somewhat  rather  than 
make  the  filling  weak  and  render  the  filled  tooth  subject  to  the 
danger  of  being  split  in  mastication.  When  the  filling  is  ground 
to  the  proper  form  with  the  stone  it  may  be  finished  with  a  moose- 
hide  or  rubber  point  carrying  moistened  silex  till  all  the  scratches 
left  by  the  stone  are  removed,  after  which  a  high  polish  may  be 
given  it  with  whiting. 

Occlusal  Fillings  in  Bicuspids  and  Molairs 

The  plan  of  building  these  fillings  varies  somewhat  according  to 
the  extent  and  form  of  the  cavity.  A  narrow  deep  cavity  calls 
for  an  arrangement  of  the  pellets  of  gold  different  from  that  of  a 
broad  and  comparatively  shallow  cavity.  In  the  narrow  cavity 
the  entire  area  of  the  pulpal  wall  or  seat  may  be  covered  by  the 


188  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

first  piece  of  gold  inserted  so  that  it  is  wedged  between  the 
surrounding  walls,  and  the  filling  may  grow  from  this  in  regular 
layers  at  right  angles  with  the  long  axis  of  the  tooth  till  the 
cavity  is  full.  In  a  broad  cavity  this  is  not  practicable.  The 
filling  must  be  started  in  one  extremity  of  the  cavity  and  carried 
across  the  pulpal  wall  pellet  by  pellet,  till  a  sufficient  number 
have  been  placed  to  reach  from  one  perpendicular  wall  to  another. 

The  idea  in  fastening  these  fillings  in  position  against  possible 
dislodgment  is  to  securely  lock  the  gold  between  the  surrounding 
walls  of  the  cavity  and  into  the  angle  formed  by  the  junction  of 
these  walls  with  the  pulpal  wall  or  seat.  If  these  angles  are 
formed  on  correct  mechanical  principles  and  the  pulpal  wall  is 
made  flat,  as  suggested  in  considering  cavity  preparation,  the 
gold  may  be  inserted  with  the  greatest  facility  and  the  filling 
anchored  beyond  the  possibility  of  displacement  under  stress  of 
mastication.  The  wear  on  these  fillings  is  often  very  severe, 
and  the  gold,  in  order  to  do  the  most  permanent  service,  must  not 
only  be  perfectly  adapted  to  the  walls,  but  must  be  made  dense 
and  hard.  As  has  already  been  stated,  the  hardness  of  gold 
can  be  largely  increased  by  continued  malleting,  even  after  com- 
pactness has  been  reached,  and  in  the  insertion  of  these  fillings 
the  operator  should  take  advantage  of  this  fact  in  order  to  secure 
as  perfect  a  wearing  surface  to  his  fillings  as  possible.  As  the 
last  pieces  of  gold  are  added  the  malleting  should  be  carried  some- 
what beyond  the  point  of  compactness,  until  the  operator  can 
detect  a  hard,  metallic  ring  to  the  surface  of  the  filling.  This 
does  not  imply  prolonged  or  injudicious  hammering  on  the  gold 
to  the  injury  of  the  pericemental  membrane  or  the  enamel- 
margins.  Care  should  be  exercised  not  to  go  beyond  the  ne- 
cessities of  the  case,  but  the  idea  should  ever  be  present  that, 
these  fillings,  more  than  all  others,  require  the  greatest  density 
and  the  highest  degree  of  resisting  power. 

If  an  operator  will  consider  carefully  the  amount  of  aggregate 
service  which  such  a  filling  is  likely  to  be  called  upon  to  perform  in 
the  course  of  its  allotted  life,  he  will  be  more  seriously  impressed 
with  the  necessity  for  the  greatest  care  and  thoroughness  in  its 
condensation.  The  repeated  impact  in  the  process  of  mastica- 
tion aggregates  enormously  in  a  single  year,  and  a  filling  inserted 
in  the  mouth  of  an  individual  of  early  or  middle  life  with  an 
expectancy  of  twenty,  thirty,  or  even  forty  years'  service  must 
needs  be  of  the  highest  order  of  excellence  to  meet  the  require- 


INTRODUCTION   AND    FINISHING   OF   GOLD   FILLINGS  189 

ments.  As  has  already  been  intimated,  the  proper  mastication 
of  an  ordinary  meal  involves  at  least  one  thousand  occlusions. 
Supposing  that  the  force  of  one-half  or  even  one-fourth  of  these 
falls  on  a  certain  tooth,  the  number  of  impacts  on  that  tooth  in  the 
course  of  a  twelvemonth  is  seen  to  be  very  great.  Multiply  this  by 
the  number  of  years  such  a  tooth  is  likely  to  be  called  on  for 
service,  and  the  sum  becomes  well-nigh  appalHng.  The  force  of 
these  impacts  varies  in  different  mouths,  and  there  is  also  a 
considerable  range  in  the  degree  required  for  the  comminution  of 
the  different  kinds  of  food  material  in  the  same  mouth;  but  the 
lowest  force  necessary  for  ordinary  mastication  is  at  least  great 
enough  to  become  an  important  factor  in  determining  the  degree 
of  density  required  of  a  filling  against  which  it  is  brought  to  bear. 

In  an  extended  study  of  the  greatest  possible  force  that  could 
be  exerted  by  closure  of  the  human  jaws,  the  late  Dr.  G.  V.  Black 
found  that  upon  the  molars  it  ranged  from  twenty-five  pounds  to 
three  hundred  pounds,  and  that  the  force  in  common  use  in 
mastication  was  greatly  in  excess  of  preconceived  ideas  on  the 
subject. 

Suppose,  then,  a  filling  on  the  occlusal  surface  of  a  lower 
molar  with  the  cusp  of  an  upper  molar  occluding  directly  against 
it,  and  this  filling  at  each  meal  receiving  the  impact  of  the  upper 
cusp  crushing  food-material  between  it  and  the  filling  at  the  rate 
estimated,  it  will  readily  become  apparent  that  to  do  permanent 
service  the  material  of  which  the  filling  is  made  must  be  capable 
of  withstanding  considerable  wear. 

The  reason  that  many  fillings  of  poor  structure  have  been 
known  to  save  teeth  for  years  is  accounted  for  in  the  fact  that 
they  have  been  so  situated  with  relation  to  the  opposing  tooth 
that  the  particular  filling  in  question  has  not  received  the  full 
force  of  masticatory  usage,  but  such  a  possible  contingency  as 
this  should  not  deter  an  operator  from  making  his  filhngs  uni- 
formly of  the  highest  degree  of  excellence.  If  we  could  have  the 
record  of  all  the  fillings  which  have  failed  as  the  result  of  imperfect 
condensation,  and  place  it  beside  the  number  of  such  filhngs 
that  have  succeeded,  the  evidence  would  be  overwhelmingly 
in  favor  of  dense  fillings. 

Insertion  of  Gold  in  Occlusal  Cavities  in  Lower  Molars. — Usually 
these  cavities  are  so  large  in  area  that  the  gold  must  be  started 
in  one  extremity  of  the  cavity  and  carried  across  the  pulpal 
wall  toward  the  other  extremity  piece  by  piece,  instead  of  wedging 


190  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

from  one  wall  to  the  other  at  the  beginning.  Fillings  of  this  char- 
acter should  ordinarily  be  started  in  that  portion  of  the  cavity 
most  remote  from  the  operator,  and  built  progressively  toward 
the  wall  nearest  him.  A  rope  of  non-cohesive  gold  should  first 
be  carried  into  the  angle  formed  by  the  junction  of  the  distal  wall 
of  the  cavity  with  the  pulpal  wall  or  seat,  and  into  this  non- 
cohesive  gold  should  be  forced  a  cylinder  of  cohesive  gold  and  the 
whole  mass  driven  to  place  with  hand  pressure,  followed  by  the 
mallet.  The  cohesive  cylinders  should  now  be  added  one  after 
the  other,  with  their  sides  against  the  mass  of  gold  already  in 
place,  and  each  cylinder  condensed  by  mallet  force  over  its 
entire  surface.  The  ends  of  the  cylinders  should  look  toward  the 
pulpal  wall  and  the  occlusal  surface  of  the  filling,  except  that  as 
the  filling  is  being  built  forward  the  portion  near  the  pulpal  wall 
should  be  slightly  in  advance  and  extend  farther  toward  the 
mesial  than  that  at  the  occlusal  surface.  This  presents  an  in- 
clined surface  of  gold  to  the  operator  against  which  the  plugger 
point  may  have  a  direct  bearing,  and  the  cylinders  should  be  laid 
with  their  sides  upon  this  incline.  Each  cylinder  should  be  long 
enough  if  possible  to  reach  from  the  pulpal  wall  to  the  extreme 
elevation  of  the  occlusal  surface  of  the  filling. 

As  the  point  is  reached  where  the  cavity  widens  out  buccally 
and  lingually  between  the  mesial  and  distal  cusps,  care  should  be 
exercised  to  wedge  the  gold  securely  into  the  angles  formed  by  the 
junction  of  the  pulpal  wall  with  the  lingual  and  buccal  extremities 
of  the  cavity.  These  portions  of  the  filling  are  sometimes  lifted 
out  of  place  by  the  use  of  adhesive  materials  such  as  sticky 
candy,  etc.,  unless  the  precaution  is  taken  to  so  deepen  the  cavity 
at  these  points  as  to  afford  ample  retention,  and  then  condense 
the  gold  firmly  into  place. 

There  are  two  points  from  this  to  the  completion  of  the  filling 
which  demand  especial  attention — the  wall  which  looks  toward 
the  mesio-lingual  cusp  on  left  lower  molars  and  the  mesio-buccal 
cusp  on  right  lower  molars,  and  also  the  mesial  extremity  of 
cavities  on  either  side  of  the  mouth.  Unless  the  operator  be 
very  cautious,  these  places  will  be  bridged  over  and  the  filling 
fail  of  perfect  adaptation  and  density.  As  has  already  been 
intimated,  the  difficulty  of  approaching  these  walls  by  mallet 
force  renders  necessary  the  use  of  curved  pluggers  to  pull  the 
gold  into  position. 

When  the  walls  are  protected  and  the  filling  built  flush  with  the 


INTRODUCTION   AND    FINISHING   OF   GOLD   FILLINGS  191 

masticating  surface,  the  entire  area  of  exposed  gold  should  be 
thoroughly  malleted  to  perfect  density.  This  may  be  done  with 
pluggers  of  shallow  serrations  or  no  serrations  at  all,  and  the  final 
blows  of  the  mallet  should  be  struck  along  the  margins  of  the 
filling. 

Insertion  of  Gold  in  Occlusal  Cavities  in  Upper  Molars. — These 
cavities  are  usually  of  such  an  area  that  the  first  piece  of  gold 
inserted  may  be  made  to  cover  the  entire  pulpal  wall  so  as  to 
wedge  between  the  surrounding  walls.  A  non-cohesive  rope  of 
sufficient  size  to  fill  about  one-third  of  the  cavity  should  be  used 
to  start  the  filling,  and  into  this  the  cohesive  cylinders  may  be 
interlaced  till  the  two  forms  of  gold  are  locked  together.  When 
the  filling  is  nearly  completed  the  cylinders  should  be  carefully 
laid  in  regular  layers,  with  their  sides  upon  the  filling  already  in 
place,  and  condensed  with  pluggers  having  shallow  serrations, 
to  the  end  that  the  surface  of  the  filling  may  be  made  uniformly 
dense  and  even. 

In  those  long,  narrow  fissure  cavities,  such  for  instance  as 
those  which  follow  the  disto-lingual  groove,  the  filling  should  be 
started  in  one  extremity  of  the  cavity  and  built  progressively 
across  to  the  other  extremity,  but  the  same  principle  of  wedging 
the  gold  between  the  two  lateral  walls  of  the  cavity  should  be 
followed  throughout.  The  fact  should  never  be  lost  to  view  that 
in  the  insertion  of  all  gold  fillings,  no  matter  where  located,  the 
prime  requisite  for  success  is  adaptation  of  the  gold  to  the  walls. 
This  is  more  important,  if  possible,  even  on  these  occlusal  surfaces, 
than  a  high  degree  of  density,  and  yet  the  thorough  and  careful 
operator  will  not  stop  short  of  securing  perfect  adaptation  and 
high  density. 

Insertion  of  Gold  in  Occlusal  Cavities  in  Bicuspids. — The  most 
difficult  fillings  to  insert  successfully  on  any  of  the  occlusal 
surfaces  are  those  in  the  small  round  pit  cavities  sometimes 
found  on  lower  bicuspids.  They  appear  to  be  the  simplest 
possible  form  of  cavity  to  fill,  and  yet  they  really  demand  a  higher 
order  of  skill  than  cavities  of  much  larger  area.  Unless  the  cavity 
has  well-defined  angles  and  a  flat  pulpal  wall  the  gold  has  a 
tendency  to  roll  under  pressure,  and  there  seems  to  be  an  es- 
pecial difficulty,  particularly  with  beginners,  in  securing  good 
adaptation  to  the  walls  of  these  round  holes.  Then  in  some 
instances  the  occlusal  portion  of  the  filling  is  inclined  to  loosen 
as  the  final  malleting  is  being  done  and  come  away  from  the  gold 


192  PRINCIPLES    AND    PRACTICE    OF   FILLING    TEETH 

in  the  depth  of  the  cavity,  leaving  a  httle  peg  of  gold  to  which 
it  seems  almost  impossible  to  attach  any  fresh  gold. 

The  proper  method  of  inserting  these  fillings  is  to  use  a  mass  of 
non-cohesive  gold  of  sufficient  size  to  fill  at  least  one-half  of  the 
cavity,  and  force  a  round  plugger  slightly  less  in  area  than  the 
cavity  into  the  center  of  the  mass  and  wedge  it  in  every  direction 
with  hand  pressure  wielded  in  the  swaying  motion  before  referred 
to.  This  leaves  a  depression  in  the  middle  of  the  filling,  with 
some  non-cohesive  gold  standing  up  against  the  surrounding 
walls  of  the  cavity.  A  small  cylinder  of  cohesive  gold  should 
now  be  wedged  into  the  depression  in  the  non-cohesive  gold  with 
hand  pressure,  and  the  whole  mass  forced  in  all  directions — 
toward  the  pulpal  wall  and  against  the  surrounding  walls.  The 
pressure  should  be  very  vigorous,  but  the  manipulation  must  not 
be  kept  up  too  long  through  fear  of  overworking  the  surface  and 
rendering  it  difficult  to  attach  more  gold  to  it.  Most  of  the 
filling  should  thus  be  built  up  by  hand  pressure  on  the  wedging 
principle,  and  the  mallet  used  only  on  the  immediate  surface. 
If  this  plan  be  followed  the  operator  will  secure  good  adaptation 
to  the  walls  through  the  medium  of  the  non-cohesive  gold,  and 
the  two  kinds. of  gold  will  be  so  wedged  or  interlaced  together 
that  the  surface  of  the  filling  will  not  flake  off. 

In  cavities  long  and  narrow,  such  as  are  ordinarily  found  in 
upper  bicuspids  and  in  lower  second  bicuspids,  the  method  of 
inserting  the  gold  is  the  same  as  for  similarly  formed  cavities  in 
molars.  The  gold  should  be  started  in  the  distal  region  of  the 
cavity  and  built  across  to  the  mesial.  The  point  in  these  fillings 
requiring  especial  care  in  adaptation  is  in  the  angle  formed  by  the 
junction  of  the  mesial  with  the  pulpal  wall.  Unless  the  operator 
watch  this  angle  carefully,  he  will  be  likely  to  bridge  the  gold  over 
it  and  leave  an  imperfection  in  the  filling. 

Finishing  Gold  Fillings  on  the  Occlusal  Surfaces  of  Bicuspids 
and  Molars. — As  soon  as  the  filling  is  thoroughly  condensed  it  is 
ordinarily  well  to  remove  the  rubber  dam  before  finishing.  The 
operator  should  make  it  a  rule  not  to  encumber  his  patient  longer 
than  possible  with  this  necessary  but  disagreeable  adjunct  to  the 
operation,  especially  in  view  of  the  fact  that  these  fillings  can 
usually  better  be  finished  without  it.  The  most  effective  means 
of  dressing  the  filling  to  form  is  by  the  use  of  carborundum  stones 
in  the  engine,  and  these  should  invariably  be  kept  moist  to 
facilitate  the  cutting  of  the  stone  and  to  prevent  heat.     The  form 


INTRODUCTION   AND   FINISHING   OF   GOLD   FILLINGS  193 

of  stone  best  adapted  for  most  cases  is  the  wheel,  and  they  should 
range  in  sizes  from  a  very  large,  thick  wheel  to  a  small,  narrow 
form  to  meet  the  varying  cases  presented.  Care  should  be  taken 
to  test  the  occlusion  by  repeated  closure  of  the  teeth,  to  be 
assured  that  the  filling  is  not  left  so  high  that  an  opposing  cusp 
impinges  too  hard  upon  it. 

When  the  filling  is  ground  to  the  desired  form  it  will  be  found 
that  the  stone  has  left  its  surface  covered  with  scratches,  which 
must  be  removed  in  order  to  give  it  a  finished  appearance.  This 
may  ordinarily  best  be  done  with  moistened  silex  carried  on  a 
moose-hide,  leather,  or  rubber  wheel,  and  when  the  filUng  is  per- 
fectly smooth  some  whiting  may  be  substituted  for  the  silex  and 
a  bright  polish  given  the  surface. 

In  certain  cases  these  occlusal  fillings  may  be  finished  to  advan- 
tage with  sand-paper  disks  by  tipping  the  disk  at  an  angle  and 
compressing  it  into  place  with  a  ball  burnisher.  In  filhngs  of 
narrow  area  situated  in  depressions  between  cusps  it  is  often 
difficult  to  reach  them  with  stones  without  cutting  the  surround- 
ing enamel.  In  these  cases  small  finishing  burs  may  be  used 
with  short,  sharp  blades  to  dress  the  filhng  to  form,  when  it  may 
be  poHshed  with  silex  and  whiting  on  wood  points  carried  in  the 
engine.  In  other  cases  these  filhngs  may  be  advantageously 
reached  by  winding  a  short  finishing  strip  on  a  small  slot  mandrel 
in  the  engine. 

Buccal,  Labial,  or  Lingual  Fillings 

The  same  principles  of  inserting  the  gold  apply  to  these  cavities 
that  have  just  been  advocated  for  occlusal  fillings — viz.,  in  all 
cavities  of  sufficiently  limited  area  the  first  piece  of  gold  inserted 
may  be  made  to  cover  the  entire  pulpal  wall  and  wedge  between 
the  surrounding  walls,  and  the  filling  built  up  in  regular  layers 
parallel  with  the  pulpal  wall,  while  in  cavities  too  extensive  for 
such  an  arrangement  the  gold  must  be  started  in  an  extremity 
of  the  cavity  and  built  across  the  pulpal  wall  piece  by  piece 
toward  the  other  extremity.  In  either  case  the  chief  requisites 
relate  to  perfect  adaptation  to  cavity-walls  and  a  reasonable 
degree  of  density  to  the  gold.  As  the  surface  of  the  filhng  is 
approached  the  aim  should  be  to  lay  the  cyHnders  on  in  a  regular 
order,  so  as  to  obtain  as  nearly  as  may  be  an  even  surface  which 
will  not  demand  much  cutting  to  finish  it. 

There  is  one  point  in  the  insertion  of  these  filhngs  which  calls 

13 


194  PRINCIPLES    AND    PRACTICE    OP    FILLING    TEETH 

for  especial  attention — the  gingival  enamel-margin.  Great  care 
should  be  exercised  as  the  filling  is  being  inserted  to  adequately 
protect  the  margin  without  building  a  large  mass  of  gold 
over  it.  The  slightest  deficiency  of  gold  at  this  point  jeopardizes 
the  operation  and  mars  an  otherwise  perfect  filling,  while  a  great 
excess  of  gold  leads  to  a  pecuharly  irksome  procedure  in  its 
removal.  The  operator  therefore  should  study  carefully  the 
outline  of  the  cavity  as  he  is  inserting  the  gold,  and  should  aim 
to  reproduce  the  original  form  of  the  tooth  with  just  sufficient 
excess  of  gold  to  make  certain  of  a  perfect  finish,  A  little  extra 
care  at  this  stage  of  the  operation  will  save  much  time  and 
annoyance  subsequently. 

Finishing  the  Filling. — -Usually  the  most  effective  means  of 
dressing  these  filHngs  to  form  is  to  employ  a  sand-paper  disk  in  the 
engine,  and  for  the  proper  approach  of  the  disk  it  is  ordinarily 
necessary  to  remove  the  clamp.  But  in  every  instance  where 
possible  the  rubber  dam  should  be  left  in  position  till  the  filling  is 
finished,  for  the  purpose  of  keeping  blood  and  saliva  away  from 
the  disk,  and  also  to  afford  protection  to  the  gum  and  avoid  its 
laceration.  The  dam  may  be  held  back  so  as  to  expose  the  filling 
with  the  fingers  of  the  left  hand,  or  by  a  hand  instrument  with 
its  point  pressed  against  the  surface  of  the  tooth  rootwise  of  the 
gingival  margin  of  the  filling.  The  disk  should  be  smeared  with 
vaseline  or  some  suitable  lubricant  to  prevent  heating  the  filling, 
and  also  to  allow  it  to  play  freely  against  the  rubber  dam  without 
cutting  or  catching  in  it  and  rolling  it  up. 

When  the  filling  is  dressed  to  the  proper  form  a  beautiful  polish 
may  be  given  it  with  a  cuttlefish  disk  or  with  a^  small  rubber  cup 
on  a  mandrel  carrying  silex,  followed  by  whiting.  Care  should  be 
exercised  in  finishing  these  fillings  to  avoid  as  largely  as  possible 
any  undue  laceration  of  the  gums.  Some  slight  irritation  of  the 
free  margin  of  the  gum  is  often  unavoidable,  and  need  not  be  con- 
sidered serious,  but  when  the  gum  is  badly  cut  or  torn  it  is  not 
always  reproduced  in  as  perfect  a  condition  as  it  originally  was, 
and  the  healing  is  sometimes  a  slow  and  discouraging  process. 
With  ordinary  precaution  the  gum  may  be  so  protected  from 
injury  as  to  entirely  recover  from  the  operation  in  a  day  or  two, 
and  lap  over  the  gingival  portion  of  the  filling  in  a  healthy  pink 
condition. 


CHAPTER  X 

MANIPULATION  OF  PLATINUM -AND -GOLD  IN  FILLING 

TEETH 

This  material  comes  to  us  in  two  forms  from  the  manufacturer 
— in  the  rolled  form  the  same  as  the  heavier  golds,  and  in  the 
form  of  folds  made  from  thinner  foils.  It  is  a  matter  of  indi- 
vidual preference  which  form  is  used.,  though  for  ordinary  work 
the  folds  will  be  found  a  trifle  more  obedient  to  the  plugger  and 
more  easily  managed  than  the  heavier  forms.  The  folds  are 
about  an  inch  in  width,  and  may  be  cut  into  strips  of  a  con- 
venient size  for  the  case  in  hand.  There  are  three  shades,  1,  2, 
and  3,  the  former  having  a  predominance  of  gold  and  showing 
a  decidedly  yellow  color  on  finishing,  shade  2  containing  a  larger 
percentage  of  platinum  and  showing  more  of  a  platinum  color 
than  shade  1,  while  shade  3  gives  a  decidedly  gray  color  almost 
like  pure  platinum.  The  shades  may  be  varied  in  the  mouth  to 
suit  the  case,  though  for  ordinary  use  shades  1  or  2  will  be  found 
preferable.  Shade  3  is  so  deep  a  platinum  color  that  in  certain 
lights  in  the  mouth  it  looks  almost  black,  and  is  thus  more 
objectionable  than  gold. 

The  chief  points  of  distinction  between  the  management  of  gold 
foil  and  the  management  of  platinum-and-gold  relate  to  the  an- 
nealing and  the  method  of  condensing.  Platinum-and-gold  re- 
quires greater  care  in  annealing  to  the  end  that  it  be  not  in  the 
least  overheated,  particularly  if  the  folds  are  used  and  the  anneal- 
ing is  done  in  a  flame.  To  pass  a  strip  through  the  flame  in  the 
ordinary  way  will  almost  invariably  result  in  the  ends  curling  up 
and  the  gold  shade  disappearing  entirely,  leaving  a  pure  platinum 
shade.  These  ends  when  thus  overheated  are  harsh,  unworkable, 
and  wholly  unreliable.  In  every  instance  where  by  any  inad- 
vertence platinum-and-gold  is  so  heated  as  to  change  color  in  this 
way,  it  should  at  once  be  discarded  and  no  attempt  made  to  use 
it.  To  gain  the  best  results  in  the  manipulation  of  platinum-and- 
gold  it  should  be  annealed  over  mica  on  the  electric  annealer, 
first  placing  a  piece  of  mica  on  the  annealer  and  allowing  a  slow 

195 


196  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

steady  heat  to  thus  reach  the  material.  If  placed  directly  on  the 
annealer  it  will  sometimes  be  found  that  it  will  turn  to  a  platinum 
color. 

In  building  the  filling  with  this  material  the  operator  must  work 
a  little  slower  and  more  deliberately  than  with  gold.  It  cannot 
safely  be  added  in  as  large  masses  as  gold,  nor  is  it  so  easily 
adapted  to  walls  or  margins.  The  condensation  must  be  very 
painstaking  and  precise,  small  plugger  points  being  used  with  the 
serrations  shallow  but  sharply  cut,  and  each  piece  malleted  per- 
fectly dense  before  another  is  added. 

In  view  of  the  more  exacting  nature  of  the  work  it  is  seldom 
advisable  to  utilize  platinum-and-gold  for  the  entire  filling,  the 
most  satisfactory  results  being  obtained  by  employing  gold  for 
starting  the  filling,  and  building  it  to  a  point  along  the  walls  where 
it  approaches  the  exposed  surfaces,  and  then  completing  the 
operation  with  platinum-and-gold.  This  will  materially  shorten 
the  work  and  produce  the  most  perfect  filling,  on  account  of  the 
more  ready  adaptation  of  gold  to  the  inaccessible  parts  of  the 
cavity.  As  the  first  pieces  of  platinum-and-gold  are  added  to  the 
gold  already  in  place  the  smallest  plugger  points  should  be  used, 
and  the  utmost  care  taken  to  force  the  platinum-and-gold  into  the 
structure  of  the  gold  so  that  the  two  are  incorporated  as  one  mass. 
If  this  precaution  is  taken  the  platinum-and-gold  will  never  sepa- 
rate from  the  gold.  As  the  extreme  surface  of  the  filling  is  ap- 
proached the  folds  should  be  laid  flat  upon  the  filling  in  precisely 
the  place  where  they  are  to  be  condensed,  and  the  malleting 
should  be  very  thorough,  with  the  impact  brought  to  bear  step  by 
step  over  every  part  of  the  surface  area  down  to  the  minutest 
points.  To  omit  even  the  smallest  area  from  this  mallet  impact 
means  that  the  portion  thus  overlooked  is  likely  to  flake  when  the 
filling  is  subjected  to  wear,  and  if  the  operator  desires  a  satis- 
factory filling  free  from  blemishes  he  cannot  give  too  close 
attention  to  the  surface  condensation. 

Platinum-and-gold,  if  thoroughly  and  uniformly  condensed, 
will  take  on  a  beautiful  finish  which  is  not  only  satisfactory  in  its 
wearing  qualities,  but  is  highly  artistic  in  appearance.  In  fact,  it 
may  truly  be  said  that  to  produce  a  perfect  platinum-and-gold 
filling  is  to  attain  the  highest  degree  of  excellence  in  the  art  of 
filling  teeth. 


CHAPTER  XI 

MANIPULATION  OF  TIN-AND-GOLD 

A  convenient  method  of  preparing  this  material  is  to  take  a 
sheet  of  No.  4  pure  tin  foil  and  lay  upon  it  a  sheet  of  No.  4  gold 
foil,  cutting  these  in  three  equal  parts,  making  strips  about  an 
inch  in  width.  These  strips  may  then  be  twisted  into  ropes  and 
cut  into  suitable  lengths  for  the  particular  use  intended.  In 
twisting  the  ropes  it  is  well  to  so  arrange  the  layers  of  foil  that  the 
tin  will  be  on  the  outside  of  the  rope,  thus  resulting  in  a  tougher 
product  and  one  easily  adapted  to  cavity-walls. 

For  building  the  gingival  third  of  deep  occluso-proximal 
fillings  in  bicuspids  and  molars,  as  already  suggested,  the  ropes 
of  tin-and-gold  may  be  used  much  in  the  same  manner  that  was 
advocated  for  gold  alone,  except  that  the  plugger  points  should  be 
more  coarsely  serrated,  and  nothing  but  hand  pressure  used  in 
forcing  the  tin-and-gold  to  place.  The  ropes  should  be  vigorously 
wedged  to  position  into  the  angles  and  between  the  cavity-walls, 
the  swaying  motion -of  the  plugger  being  especially  indicated, 
and  the  very  greatest  amount  of  force  used  consistent  with  safety 
to  walls  and  margins.  One  cardinal  point  in  the  manipulation  of 
this  material  should  never  be  lost  to  view — the  danger  of  over- 
manipulation.  The  plugger  should  be  brought  down  upon  it  at  a 
given  point  with  slow,  strong,  wedging  force,  and  as  large  a  mass 
of  the  material  carried  to  place  as  possible  with  this  one  thrust. 
The  next  position  taken  by  the  plugger  point  should  be  deliberate 
and  carefully  directed,  and  another  area  of  the  mass  condensed  in 
the  same  manner.  If  manipulated  in  this  way  the  material  will 
go  to  place  readily  and  remain  there,  while  the  integrity  of  the 
resultant  mass  will  not  be  impaired,  but  if  the  material  is  in  the 
least  degree  overworked  by  the  plugger  it  chops  up  and  disinte- 
grates so  as  to  ruin  it.  Many  operators  have  failed  to  get  satis- 
factory results  with  this  material  on  account  of  overmanipulation. 
After  the  requisite  amount  of  tin-and-gold  has  been  forced  to 
position  with  hand  pressure,  the  surface  will  present  coarse  inden- 
tations resulting  from  the  deep  serrations  of  the  plugger,  and  into 

197 


198  PRINCIPLES    AND    PRACTICE    OP    FILLING    TEETH 

this  surface  should  be  incorporated  cohesive  gold  cylinders, 
using  the  same  plugger  with  hand  pressure  till  the  gold  reaches 
from  the  buccal  to  the  lingual  wall.  As  soon  as  the  gold  is 
securely  locked  across  between  these  two  walls  and  interwoven 
into  the  tin-and-gold,  the  coarse  plugger  should  be  laid  aside  and 
a  plugger  with  shallower  serrations  substituted  for  it.  Up  to 
this  point  the  process  has  been  one  of  wedging  with  hand  pressure 
and  an  interlacing  of  the  layers  of  tin-and-gold  together,  and 
also  of  the  gold  cylinders  into  the  tin-and-gold.  There  is  no 
cohesion  between  the  tin-and-gold,  nor  between  this  and  the 
cohesive  gold,  so  that  they  must  be  interwoven  in  the  manner 
indicated.  But  from  this  point  the  mallet  should  be  used  and  the 
layer  of  cohesive  gold  should  be  very  vigorously  malleted  down 
onto  the  tin-and-gold  till  the  entire  mass  is  made  compact 
and  dense.  From  this  the  filling  is  completed  with  gold  in  the 
ordinary  way. 

The  finishing  and  polishing  of  the  tin-and-gold  at  the  gingival 
margin  is  in  nowise  different  from  that  advocated  for  gold. 

In  filling  occlusal  cavities  in  bicuspids  and  molars  for  children 
with  this  material,  a  rope  should  be  selected  if  possible  large 
enough  to  fill  the  entire  cavity  and  leave  a  sufficient  surplus  for  a 
perfect  finish.  If  the  cavity  is  found  to  be  too  extensive  for  one 
rope  to  fill,  care  should  be  taken  that  the  first  rope  used  shall  not 
be  so  large  as  to  carry  the  filling  too  near  the  occlusal  surface.  In 
other  words,  the  final  rope  should  be  allowed  to  extend  sufficiently 
into  the  cavity  to  be  firmly  locked  between  the  surrounding  walls 
and  be  retained  by  reason  of  this  locking  rather  than  from  any 
union  between  it  and  the  mass  already  in  place.  Tin-and-gold, 
as  has  been  said,  is  not  cohesive,  and  while  the  layers  may  be 
interwoven  to  a  certain  degree,  yet  the  union  thus  formed  cannot 
be  considered  sufficiently  secure  to  hold  the  final  piece  in  place 
against  any  appreciable  wear.  If  the  operator  finds  in  condens- 
ing the  first  rope  that  it  is  likely  to  carry  the  filling  too  close  to 
the  occlusal  surface,  he  should  tear  off  a  piece  and  lay  it  aside  so 
as  to  leave  an  appreciable  depth  to  the  cavity  before  adding  the 
last  rope.  This  use  of  two  or  more  ropes  instead  of  making  a 
single  rope  of  sufficient  size  to  fill  any  of  these  occlusal  cavities 
is  advocated  because  of  the  unwieldy  nature  of  a  rope  which  is 
much  greater  than  an  inch  in  length. 

In  view  of  the  fact  that  it  is  seldom  advisable  to  use  this  ma- 
terial in  cavities  having  a  very  broad  area  presented  to  the  oc- 


MANIPULATION    OF   TIN-AND-GOLD  199 

clusal  surface,  on  account  of  the  tendency  to  rapid  wear  under 
such  conditions,  the  usual  method  of  inserting  the  filHng  is  to 
wedge  between  surrounding  walls,  the  limit  of  the  cavity  ordi- 
narily being  such  as  to  permit  of  this  plan.  The  rope  should  be 
grasped  by  the  pliers  about  five  or  six  millimeters  from  the  end, 
and  this  end  carried  into  the  cavity  so  as  to  fold  upon  itself  against 
the  pulpal  wall.  The  rope  should  then  be  grasped  a  little  farther 
back  and  folded  again  into  the  cavity,  this  process  being  kept 
up  till  sufficient  of  the  rope  has  been  gathered  into  the  cavity  to 
constitute  an  appreciable  mass  when  condensed  and  permit  of 
being  wedged  between  the  surrounding  walls  ofthe  cavity.  If  the 
cavity  is  so  deep  that  it  will  require  more  than  one  rope  to  fill  it, 
the  first  rope  may  be  nearly  all  carried  to  place  with  the  pliers 
before  the  plugger  is  used  to  condense  it,  but  if  only  one  rope  is 
required  the  condensation  should  begin  after  the  first  half  has 
been  forced  into  place  and  while  the  other  half  is  still  hanging 
free  from  the  cavity. 

The  manner  of  condensing  is  by  hand  pressure,  using  a  stiff- 
shanked,  coarsely  serrated  plugger.  This  should  be  forced  to- 
ward the  pulpal  wall  in  the  middle  of  the  mass  of  material,  and 
then  vigorously  swayed  in  every  direction  to  carry  the  material 
snug  and  tight  against  the  surrounding  walls,  using  as  much  force 
in  these  movements  as  can  safely  be  done  short  of  injury  to  tooth- 
tissue  or  the  pericemental  membrane.  The  same  precaution 
against  overmanipulation  is  necessary  here  as  with  the  gingival 
portion  of  proximal  fillings.  When  a  few  vigorous  and  effective 
wedging  movements  have  been  made  against  the  mass,  some  more 
of  the  rope  should  be  gathered  into  position  and  the  wedging 
continued.  As  the  surface  is  approached  the  free  end  of  the 
rope  should  be  folded  over  so  as  to  look  toward  the  pulpal  wall, 
and  it  should  be  forcibly  driven  into  the  mass  of  filling-material 
and  interwoven  with  it,  leaving  the  looped  side  of  the  rope 
presented  to  the  occlusal  surface.  Care  should  be  taken  to  have 
the  material  somewhat  more  than  flush  with  the  orifice  of  the 
cavity,  but  this  surplus  should  not  be  manipulated  to  any  extent 
with  the  plugger  point.  For  the  surface  condensation  a  large  ball 
burnisher  should  be  used,  and  the  filling  vigorously  burnished 
into  the  cavity  and  against  the  margins  till  the  surface  is  as  hard 
as  this  material  will  permit. 

To  dress  the  filling  to  form  and  give  it  an  even  surface  a  fine 
carborundum  stone  may  be  used  in  the  engine,  or  in  cases  of  a  very 


200  PRINCIPLES    AND    PRACTICE    OF   FILLING    TEETH 

small  filling  in  a  deep  depression  between  cusps  where  a  stone 
will  not  reach  a  finishing  bur  may  be  substituted.  In  places 
where  the  sand-paper  disk  may  be  made  to  reach  the  filHng  by 
forcing  it  to  place  with  a  ball  burnisher,  this  will  be  found  the 
ideal  method  of  finishing  these  fillings. 

The  use  of  tin-and-gold  in  these  small  occlusal  cavities  in  chil- 
dren's teeth  is  strongly  advocated  in  preference  to  amalgam. 
Contrary  to  the  prevailing  impression  in  regard  to  the  matter,  it 
can  be  inserted  more  expeditiously  than  amalgam,  and  if  properly 
manipulated  it  is  more  certain  in  its  results.  It  is  less  treacherous 
than  amalgam.  If  it  fails  it  does  so  in  a  manner  at  once  recog- 
nized, while  amalgam  may  appear  perfect  to  the  naked  eye  and 
yet  be  leaking  so  badly  as  to  cause  the  enamel  to  be  undermined 
by  decay  for  a  considerable  area  around  the  deeper  portions  of  the 
filling.  Tin-and-gold  does  not  shrink  or  change  form  as  does 
much  of  the  amalgam  in  use,  and  it  is  accordingly  a  better  protec- 
tion to  the  cavity-walls.  If  an  operator  becomes  expert  in  its 
manipulation  he  will  find  a  large  range  of  usefulness  for  it  in  his 
practice,  and  it  will  not  prove  a  disappointment. 

In  using  tin  foil  for  filling  teeth,  the  same  general  plan  of 
manipulation  is  indicated  as  that  just  outlined  for  tin-and-gold. 


CHAPTER  XII 

MANIPULATION  OF  AMALGAM 

It  may  be  considered  scarcely  practicable  to  lay  down  any  in- 
variable rule  in  regard  to  the  percentage  of  mercury  which  must  be 
mixed  with  an  alloy  to  gain  the  best  results  in  an  amalgam.     The 
vast  number  of  alloys  on  the  market  and  the  variable  require- 
ments in  the  different  makes  render  the  question  of  percentage  a 
difficult  one.     The  most  that  can  be  done  is  to  suggest  in  a  general 
way  the  manner  of  mixing  the  alloy  with  the  mercury,  and  in- 
dicate as  accurately  as  may  be  the  proper  consistence  or  plasticity 
of  the  mass  to  secure  the  best  results.     While  it  is  a  mooted 
question  as  to  whether  or  not  it  may  be  injurious  to  an  amalgam 
to  so  mix  it  that  an  excess  of  mercury  is  added  and  subsequently 
wrung  out  before  inserting  the  filling,  it  will  be  found  that  prac- 
tically under  present  conditions  the  most  uniform  product  may  be 
obtained  in  that  way.     If  manufacturers  would  put  up  their 
alloy  in  small  capsules  with  an  accompanying  capsule  of  mercury 
accurately  weighed  out  in  the  per  cent,  that  has  been  demon- 
strated by  experiment  to  be  the  best  for  that  particular  alloy,  it 
might  be  practicable  to  so  mix  amalgam  in  office  work  that  there 
need  never  be  any  free  mercury  present;  but  the  fact  that  this 
experiment  has  been  tried  by  at  least  one  manufacturer  and 
failed  to  receive  the  support  of  the  profession  would  seem  to 
indicate  that  the  profession  was  not  willing  to  yield  this  much 
homage  to  the  material.     Neither  can  it  be  expected  that  prac- 
titioners generally  will  ever  be  persuaded  to  take  the  trouble  to 
weigh  out  the  exact  proportions  for  each  filling  in  the  daily  rou- 
tine of  practice,  even  where  it  is  possible  to  ascertain  the  proper 
proportion  for  the  alloy  they  are  using.     It  would  be  the  ideal 
method  if  this  could  be  done,  but  it  may  well  seem  fruitless  to 
advocate  any  method  of  practice  which  the  profession  manifestly 
will  not  follow. 

In  our  teaching  we  must  aim  to  accomplish  the  greatest  good 
to  the  greatest  number,  and  with  the  varying  alloys  on  the  market 
the  surest  way  to  do  this  is  to  give  the  technical  procedure 
necessary  to  the  best  preparation  of  the  alloy  for  filHng.     With 

201 


202  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

most  of  the  alloys  at  present  in  use  the  mass  requires  extended 
mixing  in  order  to  secure  a  perfect  incorporation  of  the  mercury 
with  the  filings.  To  do  this  it  is  advisable  to  use  a  pestle  and 
mortar  at  least  in  the  early  part  of  the  mixing.  This  mortar 
should  be  of  appreciable  size,  and  the  inner  surface  of  the  bowl 
should  be  roughened.  The  small  smooth  glass  mortars  sometimes 
offered  for  sale  for  mixing  amalgam  are  not  at  all  suited  to  the 
purpose,  there  being  insufficient  area  for  trituration  and  no  re- 
sistance to  the  gliding  of  the  mass  along  the  inner  surfaces  in 
front  of  the  pestle.  A  roughened  surface  results  in  the  ingre- 
dients being  caught  between  the  pestle  and  the  mortar  so  that  they 
receive  the  proper  amount  of  grinding. 

Sufficient  mercury  for  the  case  in  hand  should  be  placed  in  the 
mortar,  and  filings  added  little  by  little  as  the  grinding  proceeds, 
until  the  mass  reaches  a  consistence  which  would  seem  to  in- 
dicate that  if  more  filings  were  added  it  would  interfere  with  the 
plasticity  of  the  product  and  render  it  granular.  At  this  point 
it  is  well  to  transfer  the  mass  to  the  palm  of  the  hand  and  knead 
it  quite  vigorously  with  the  ball  of  the  finger  of  the  other  hand. 
This  kneading  will  usually  result  in  increasing  the  plasticity  of  the 
mass,  and  if  it  is  found  that  too  much  mercury  is  apparent  some 
more  filings  should  be  added  and  the  kneading  continued.  The 
mass  should  be  mixed  just  to  the  point  where  there  seems  to  be  a 
complete  incorporation  of  the  filings  with  the  mercury  and  where 
pressure  of  the  mass,  such  as  wringing  vigorously  in  chamois 
or  strong  linen  with  the  fingers,  will  result  in  a  minute  quantity 
of  mercury  being  expressed  from  it.  In  view  of  a  possible  dis- 
arrangement of  the  formula  of  the  alloy  by  carrying  away  more 
of  one  metal  than  another  in  the  expressed  mercury,  it  is  always 
well  to  have  the  mass  of  such  consistence  that  it  is  possible  to 
wring  out  only  a  very  small  amount.  When  the  mass  is  taken 
from  the  linen  it  should  break  apart  easily  with  little  apparent 
plasticity  to  it,  and  if  the  amalgam  is  of  the  quick-setting  variety 
it  should  be  kept  under  constant  movement  till  the  last  piece  is 
condensed  in  the  cavity.  That  is,  when  part  of  it  has  been 
placed  in  the  cavity  preparatory  to  condensing  it  the  portion 
remaining  on  the  operating  table  should  be  kneaded  by  the 
assistant  till  it  is  required,  and  if  the  operator  has  no  assistant 
he  should  manage  in  some  way  with  the  fingers  of  his  left  hand 
to  keep  the  mass  in  motion.  If  he  finds  this  impracticable  he 
would  better  select  a  slower-setting  alloy. 


MANIPULATION    OF    AMALGAM  203 


Method  of  Packing  Amalgam 


The  pluggers  used  for  this  purpose  should  he  fiat-faced  instead 
of  rounded,  and  should  be  as  large  in  area  as  can  conveniently  be 
employed  in  the  given  cavity.  The  idea  should  always  be  to 
carry  the  mass  in  front  of  the  plugger  directly  against  the  cavity- 
wall,  instead  of  having  it  squeeze  out  alongside  the  instrument. 
Amalgam  should  not  be  treated  as  if  it  were  intrinsically  a  plastic 
material  and  could  be  patted  to  position  with  little  force.  Amal- 
gam to  gain  the  best  results  must  be  condensed  by  heroic  pres- 
sure. If  too  small  an  instrument  is  used,  a  sufficient  pressure 
for  proper  condensation  will  result  in  the  plugger  piercing  the 
mass  and  driving  the  material  to  either  side  of  it.  The  aim  should 
be  to  keep  the  mass  gathered  before  the  instrument  so  that  it  is 
carried  only  in  the  direction  toward  which  the  force  is  exerted, 
and  to  accomplish  this  a  broad  flat-faced  plugger  is  necessary, 
unless  the  area  of  the  cavity  is  so  small  that  the  amalgam  is 
forced  against  the  surrounding  walls.  If  a  filling  is  to  be  made 
which  is  not  more  or  less  porous,  the  ingredients  of  the  amalgam 
must  receive  vigorous  compression.  Ptealizing  this,  some  opera- 
tors recommend  mallet  force  to  condense  amalgam,  but  it  would 
seem  to  be  immaterial  which  way  the  force  is  applied,  whether 
by  mallet  or  hand  pressure,  so  long  as  the  compression  is  suffi- 
ciently forceful. 

Recognizing  the  character  of  amalgam,  it  will  readily  be  ap- 
preciated that  to  secure  the  best  results  in  its  insertion  it  is  neces- 
sary to  have  a  cavity  with  surrounding  walls  instead  of  one  with 
an  open  aspect  and  one  wall  missing,  as  in  a  proximo-occlusal 
cavity  in  a  molar.  All  cavities,  therefore,  involving  the  proximo- 
occlusal  surfaces  should  be  reinforced  by  a  matrix  to  gain  the  best 
results  in  condensation.  In  cases  of  very  extensive  restoration 
where  the  tooth-tissue  has  been  badly  broken  down,  a  matrix 
of  thin  German  silver  should  be  made  for  the  case  Vjy  wrapping 
a  strip  of  the  material  around  the  tooth  and  tacking  the  ends 
together  with  solder.  When  this  is  slipped  over  the  tooth  it 
can  be  burnished  to  the  proper  form,  and  after  the  insertion  of 
the  filling  the  matrix  may  be  allowed  to  remain  on  the  tooth  till 
the  following  day  as  a  support  to  the  amalgam  during  the  process 
of  crystallization.  At  the  next  visit  of  the  patient  the  matrix 
may  be  cut  and  removed  and  the  filling  polished. 

The  manner  of  inserting  amalgam  is  to  take  a  small  piece  in  the 


204  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

pliers  and  carry  it  to  place  in  the  cavity,  condensing  it  thoroughly 
before  another  piece  is  added.  As  the  filling  is  thus  being  built 
up  piece  by  piece,  if  the  compression  results  in  bringing  surplus 
mercury  to  the  surface  the  soft  mass  thus  resulting  should  be 
scraped  from  the  filling  and  the  next  piece  of  amalgam  added  to 
the  harder  portion  beneath  it.  An  amalgam  filling  cannot  have 
a  satisfactory  surface  with  an  excess  of  mercury  present.  Even 
if  it  did  not  interfere  with  the  integrity  of  the  mass,  there  would 
still  remain  a  physical  reason  why  a  softened  surface  is  contra- 
indicated.  No  operator  can  be  certain  that  he  has  secured  uni- 
form adaptation  to  cavity-walls  in  the  attempt  to  condense  a  soft 
mass  of  amalgam.  This  material  under  those  conditions  acts 
relatively  like  a  mass  of  jelly,  so  that  if  the  operator  forces  it 
against  one  margin  it  is  immediately  drawn  away  from  another. 
The  only  possible  way  to  be  assured  of  adaptation  to  all  of  the 
outlines  of  a  cavity  in  the  effort  to  insert  soft  amalgam  would  be 
to  have  a  plugger  point  as  broad  as  the  area  of  the  cavity,  and 
bring  force  over  the  entire  surface  of  the  filling  at  the  same  time. 
This,  of  course,  is  seldom  feasible,  and  it  will  accordingly  be 
apparent  that  to  get  good  results  with  amalgam  and  produce  a 
filling  which  does  not  leak  at  some  point  it  must  be  used  without 
an  excess  of  mercury. 

When  the  filling  is  built  to  the  requisite  fullness  it  should  at 
once  be  trimmed  to  form  before  it  is  allowed  to  become  hard. 
The  occlusal  surface  may  be  smoothed  by  taking  a  pellet  of 
tightly  rolled  cotton  in  the  pliers  and  gently  wiping  it  across  the 
surface,  always  in  the- direction  of  the  margins.  Any  surplus 
on  the  proximal  surface  in  the  interproximal  space  must  be 
carefully  removed  at  this  sitting  with  thin  amalgam  trimmers. 
If  small  particles  of  the  material  are  allowed  to  extend  over  the 
cavity-margins  at  this  point  till  crystallization  has  taken  place 
it  will  be  found  very  difficult  to  remove  them,  and  if  they  are  not 
removed  and  the  filling  made  smooth  and  even  with  the  surface  of 
the  enamel  the  gum  in  the  interproximal  space  will  invariably 
present  an  abnormal  condition  on  account  of  the  irritation.  It  is 
necessary  to  look  as  carefully  to  the  finish  of  an  amalgam  filling 
at  this  point  as  to  a  gold  filling,  and  the  trimming  to  form  should 
invariably  be  done  while  the  amalgam  is  still  semi-plastic.  Close 
attention  should  also  be  given  to  the  occlusion,  so  that  an  op- 
posing cusp  may  not  injure  the  filling  by  too  great  impact  before 
it  is  hard. 


MANIPULATION    OF   AMALGAM  205 

When  the  fiUing  is  thus  properly  formed  the  case  may  be  dis- 
missed till  another  sitting,  at  which  time  it  should  be  polished 
with  the  same  care  and  in  the  same  manner  as  a  gold  filling. 
Amalgam  will  take  a  most  beautiful  finish,  and  if  inserted  with 
painstaking  care  along  the  lines  indicated,  and  polished  at  a 
subsequent  sitting,  the  results  in  amalgam  work  will  prove  more 
beneficial  and  more  uniformly  satisfactory  than  we  ordinarily 
see  in  the  mouths  of  our  patients. 


CHAPTER  XIII 
MANIPULATION  OF  CEMENTS 

In  the  preparation  of  cement  for  filling  teeth  the  plan  of 
mixing  is  somewhat  important.  A  quantity  of  powder  sufiicient 
for  the  case  in  hand  should  be  placed  upon  the  mixing  slab, 
and  a  short  distance  from  this  the  requisite  amount  of  liquid. 
The  means  used  to  dip  the  liquid  from  the  bottle  should  be  such 
as  not  to  contaminate  the  remaining  contents  of  the  bottle. 
The  liquid  of  cement  to  give  the  most  serviceable  working 
quality  should  be  of  a  consistence  bordering  closely  on  crystalliza- 
tion. In  fact,  a  liquid  which  presents  no  tendency  to  crystalliza- 
tion and  which  remains  permanently  fluid  under  all  circumstances 
cannot  be  considered  the  safest  kind  of  liquid  for  ordinary  use 
in  the  mouth.  This  tendency  in  most  of  the  reliable  fluids 
renders  it  necessary  to  handle  them  with  great  care,  to  avoid 
as  largely  as  possible  the  formation  of  crystals.  Crystals  are 
readily  formed  if  small  quantities  of  the  liquid  are  left  exposed 
to  the  air,  and  thus  we  find  about  the  mouths  of  the  bottles  more 
or  less  of  a  crystallized  mass,  on  account  of  leaving  a  surplus  of 
the  material  clinging  to  the  cork  and  smeared  over  the  rim  of  the 
bottle.  Small  particles  from  this  crystallized  mass  dropping  into 
the  bottle  from  time  to  time  tend  to  start  other  centers  of  crystal- 
lization in  the  fluid,  and  the  entire  contents  of  the  bottle  may  thus 
be  contaminated.  In  view  of  this  it  is  always  desirable  to  keep 
the  mouth  of  the  bottle  as  free  from  the  liquid  as  possible,  and 
consequently  the  practice  of  pouring  the  liquid  from  the  bottle 
to  the  slab  is  contraindicated.  The  liquid  should  be  carefully 
dipped  out  and  dropped  on  the  slab  by  a  glass  dropper  which  is 
not  in  any  way  acted  on  by  the  liquid. 

In  mixing  the  cement  the  powder  should  be  added  to  the  liquid 
little  by  little,  the  mass  meanwhile  being  thoroughly  stirred  and 
rubbed  with  the  spatula.  Most  operators  fail  to  mix  their  cement 
with  sufB.cient  vigor  to  obtain  a  perfect  incorporation  of  the 
powder  with  the  liquid.  The  best  results  are  gained  by  a  very 
vigorous    rubbing    over   a  considerable  area  of  the  slab — the 

206 


MANIPULATION    OF    CEMENTS  207 

powder  being  added  till  the  mass  is  almost  as  stiff  as  freshly 
prepared  putty.  If  it  is  to  be  used  for  the  temporary  sealing 
of  medicaments  in  a  cavity  or  for  any  purpose  where  pressure 
cannot  be  used  in  its  insertion,  it  may  be  left  more  plastic  so  as 
to  flow  with  little  resistance,  but  if  to  be  used  for  fillings  it 
should  be  made  reasonably  stiff  and  then  forced  into  place  with 
considerable  pressure. 

A  convenient  means  of  carrying  the  mass  from  the  spatula  to 
the  cavity  is  to  first  gather  the  cement  into  a  ball  on  the  end  of 
the  spatula,  and  then,  having  some  cotton  rolled  into  a  tight,  com- 
pact pellet,  grasp  this  firmly  with  the  pliers  and  use  it  as  a  means 
of  scraping  the  cement  from  the  spatula  to  the  cavity.  The  cot- 
ton must  be  rolled  tight  to  prevent  the  cement  from  chnging  to  it. 
Some  varieties  of  cements  are  more  adhesive  to  cotton  than 
others,  but  with  most  of  them  if  they  are  mixed  sufficiently  stiff 
to  yield  the  best  results  in  fillings  the  tight  cotton  roll  may  be 
used  very  advantageously.  When  the  cement  has  been  pressed 
to  place  in  the  cavity  with  the  cotton  and  the  excess  wiped  away, 
still  further  compression  may  be  made  with  a  broad,  smooth, 
flat-faced  plugger  just  as  the  mass  begins  to  crystallize,  but 
after  crystallization  has  once  definitely  set  in  the  filling  should 
not  be  disturbed  by  manipulation  till  it  has  become  hard.  The 
filling  should  be  dressed  to  the  proper  form  while  it  is  still  soft 
by  the  use  of  thin  instruments  of  a  form  indicated  by  the  require- 
ments of  the  case,  the  trimming  always  being  done  toward  the 
margins. 

In  using  cement  for  children's  teeth  in  those  incipient  cavities 
in  the  occlusal  surfaces  of  bicuspids  and  molars,  a  most  effective 
means  of  forcing  the  cement  to  place  and  keeping  it  dry  for  a  few 
minutes  after  its  insertion  is  to  carry  the  material  to  the  cavity  in 
the  ordinary  way  and  press  it  into  position  with  the  cotton  pellet, 
leaving  an  excess  heaped  up  over  the  vicinity  of  the  cavity.  On 
this  excess  the  ball  of  the  operator's  finger  should  be  placed,  cover- 
ing the  entire  occlusal  surface  of  the  tooth  and  forcibly  com- 
pressing the  cement  into  position  till  the  surplus  is  squeezed  out 
over  the  marginal  ridges  of  the  occlusal  surface.  The  finger 
should  be  most  vigorously  forced  against  the  tooth  and  held  there 
with  considerable  compression  till  the  cement  has  begun  to 
crystallize,  after  which  the  surface  may  be  smoothed  with  an 
instrument. 


CHAPTER  XIV 
MANIPULATION  OF  GUTTA-PERCHA 

The  great  desideratum  in  the  use  of  gutta-percha  is  to  so  regu- 
late the  heat  in  softening  it  that  the  mas§  will  be  made  sufficiently 
pliable  to  be  readily  inserted  in  the  cavity  without  in  the  slightest 
degree  overheating  the  material.  If  gutta-percha  is  brought  into 
contact  with  the  flame  it  is  almost  instantly  charred  and  ruined, 
and  should  never  be  introduced  into  a  cavity.  The  most  effective 
means  of  heating  it  is  on  a  warm  porcelain  slab  placed  some  dis- 
tance from  the  flame  so  that  the  heat  is  gradual  and  steady,  but 
if  the  operator  cannot  take  the  time  for  this  he  may  get  satis- 
factory results  by  heating  it  over  a  flame,  provided  he  exercises 
sufficient  caution.  The  pieces  of  gutta-percha  may  be  grasped 
in  the  pliers  and  held  so  far  above  the  flame  that  the  heat  is  not 
intense  enough  to  injure  the  mass,  and  when  sufficiently  warmed 
they  may  be  carried  directly  to  the  cavity  and  compressed  to 
place.  If  the  ordinary  pink  gutta-percha  base-plate  is  used — 
and  this  makes  a  more  permanent  filling  than  any  of  the  white 
preparations — there  is  another  reason  why  the  heating  should  be 
carefully  watched.  This  material  requires  greater  heat  to  render 
it  soft  than  most  other  forms,  and  it  is  therefore  inclined  to  cause 
pain  when  applied  to  a  tooth  with  a  living  pulp,  and  the  slightest 
degree  of  overheating  adds  seriously  to  the  discomfort.  The 
idea  with  any  gutta-percha  is  to  warm  with  a  low  degree  of 
heat  continued  for  some  time,  the  reason  being  that  the  conduc- 
tive properties  of  the  material  are  poor  and  it  requires  time  to 
make  the  mass  uniformly  soft.  A  rapid  heating  at  high  tempera- 
ture simply  sears  the  surface  without  softening  the  entire  piece. 

For  temporary  work  such  as  sealing  medicaments  in  teeth  the 
softer  forms  of  gutta-percha  known  as  the  temporary  stoppings 
are  preferable  to  the  base-plate.  They  are  softened  with  much 
less  heat,  are  readily  molded  to  cavity-walls,  making  perfect 
sealing  agents,  and  are  more  easily  removed.  In  using  them  care 
must  be  exercised  not  to  overheat,  because  of  the  disagreeable 
stickiness  which  too  much  heat  imparts   to  them.     If  gently 

208 


MANIPULATION    OF    GUTTA-PERCHA  209 

heated  they  may  be  made  soft  at  a  temperature  which  will 
permit  of  the  mass  being  kneaded  between  the  thumb  and  finger 
like  putty. 

In  finishing  a  gutta-percha  filling  the  surplus  may  be  trimmed 
away  with  a  heated  instrument,  dressing  always  toward  the  mar- 
gin. If  there  seems  a  tendency  for  the  gutta-percha  to  curl 
away  from  cavity-margins  the  instrument  should  be  made  just 
warm  enough  to  shghtly  soften  the  mass,  and  then  the  broad 
side  of  it  should  be  placed  forcibly  against  the  surface  of  the 
filling  and  held  there  with  considerable  compression  till  it  be- 
comes cool.     The  gutta-percha  will  then  remain  stationary. 


14 


CHAPTER  XV 
MANIPULATION  OF  THE  SILICATE  CEMENTS 

To  obtain  the  best  results  with  the  siHcates  the  first  cardinal 
requirement  is  cleanliness.  The  slightest  contamination  of  this 
material  with  foreign  matter  of  any  kind  ruins  it,  or  at  least 
detracts  from  its  best  working  properties.  The  porcelain  slab 
upon  which  it  is  mixed  should  be  kept  scrupulously  clean,  even 
from  particles  of  a  previous  mix  of  the  same  material.  No  steel 
instrument  should  be  used  in  its  manipulation  on  account  of 
the  fact  that  the  liquid  affects  steel,  and  the  material  is  con- 
taminated by  contact  with  it.  The  best  form  of  spatula  for  mix- 
ing silicates  is  the  agate  spatula,  and  the  instruments  for  inserting 
it  in  the  cavity  should  be  of  tantalum.  The  cavity  should  have 
a  decided  retentive  form,  i.e.,  the  filling  should  be  held  in  mechan- 
ically, with  no  reliance  upon  the  adhesive  properties  of  the 
material. 

To  mix  the  mass  a  requisite  amount  of  the  liquid  should  be 
placed  on  the  slab  with  a  glass  dropper,  and  the  powder  placed 
near  it.  A  small  amount  of  the  powder  is  drawn  with  the  spatula 
into  the  liquid  and  thoroughly  spatulated.  After  complete  in- 
corporation of  this  powder  with  the  liquid  some  more  powder  is 
taken  in  and  the  process  repeated — using  small  quantities  of  the 
powder  each  time — till  the  mass  is  of  the  proper  consistency. 
This  stage  is  reached  when  the  mass  is  sufficiently  thick  so  that 
it  may  be  scraped  from  the  spatula  with  the  thumb  and  finger 
and  kneaded  and  rolled  between  them  without  appreciable  stick- 
ing. This  kneading  should  be  continued  for  a  moment  before 
placing  the  mass  in  the  cavity  which  adds  much  to  its  pliability 
and  nice  working  properties.  It  goes  without  saying  that  the 
fingers  must  be  perfectly  clean  and  free  from  moisture.  After 
the  mass  has  been  kneaded  and  rolled  sufficiently  it  should  be 
stuck  to  the  end  of  the  spatula,  and  with  it  carried  to  the  cavity. 
To  force  the  mass  to  place  a  tightly  rolled  pellet  of  clean  cotton 
grasped  in  the  pliers  will  be  found  most  effective,  working  the 
material  quickly  into  the  interior  of  the  cavity  and  trimming  it  to 

210 


MANIPULATION    OF    THE    SILICATE    CEMENTS  211 

form  with  the  thin  tantalum  instrument.  After  it  is  given  the 
correct  form  it  should  not  further  be  disturbed  except  to  flow 
over  it  some  of  the  varnish  which  comes  with  the  material  to 
protect  it  against  moisture  during  crystallization.  At  a  subse- 
quent sitting  if  the  form  or  finish  of  the  filUng  is  not  satisfactory- 
it  can  then  be  trimmed  to  form  with  fine  stones  or  disks  or  strips 
and  polished  with  cuttlefish  disks  or  strips.  But  in  many  in- 
stances if  the  fiUing  has  been  carefully  trimmed  to  form  at  the 
time  of  its  insertion  it  will  present  a  surface  in  a  day  or  two 
which  is  more  satisfactory  than  any  that  can  be  given  it  by 
polishing.  This  is  a  glazed  and  vitreous  surface  which  is  so  hard, 
and  which  harmonizes  so  perfectly  with  the  natural  enamel,  that 
it  is  best  not  to  disturb  it. 

In  matching  the  shades  of  the  teeth  with  this  material  there  is  a 
wide  range  of  possibilities.  It  comes  in  different  colors  from  a 
dark  yellow  and  a  dark  gray  to  an  almost  pure  white.  It  is  sel- 
dom that  any  one  color  alone  will  perfectly  match  a  given  tooth, 
but  by  combining  them  judiciously  the  most  beautiful  results  may 
be  obtained.  It  is  possible  with  a  skillful  blending  of  the  shades 
to  perfectly  match  any  kind  of  enamel,  and  it  is  a  most  fascinat- 
ing study  to  so  combine  the  shades  as  to  obtain  perfect  results. 
This  must  be  mastered  by  each  operator  for  himself  and  only 
after  the  closest  practical  observation  of  the  effects  of  certain 
combinations  and  their  application  to  certain  shades  of  enamel. 
It  is  well  worth  all  the  study  necessary  to  master  it,  because  if 
an  operator  is  armed  with  this  ability  he  is  enabled  to  produce 
more  perfect  results  in  an  artistic  sense  than  by  any  other  method. 


CHAPTER  XVI 
MAKING  INLAY  FILLINGS 

The  two  kinds  of  inlays  most  in  use  are  the  porcelain  inlays 
for  exposed  positions  in  the  anterior  teeth,  and  gold  inlays  in  bi- 
cuspids and  molars  where  the  stress  of  mastication  is  an  impor- 
tant consideration.  Porcelain  inlays  are  made  by  fitting  a  metal 
matrix  of  gold  or  platinum — depending  on  whether  the  porcelain 
to  be  used  is  low  or  high  fusing  in  character — and  then  fusing  the 
porcelain  into  this  matrix  to  build  the  filling  to  form.  Gold 
inlays  are  made  by  forming  a  wax  model  in  the  cavity,  investing 
this  in  a  mold,  burning  the  wax  out,  and  casting  the  gold  into 
a  perfect  reproduction  of  the  wax  model. 

Each  kind  of  inlay  after  completion  is  cemented  to  the  cavity 
with  the  oxyphosphate  of  zinc. 

Porcelain  Inlays 

The  fact  has  already  been  mentioned  that  the  silicate  cements 
have  quite  generally  displaced  porcelain  as  a  filling  material,  and 
yet  no  operator  is  perfectly  equipped  to  meet  all  the  necessities 
of  a  modern  practice  without  the  ability  to  make  a  porcelain 
inlay.  Porcelain  as  a  material  will  assuredly  last  longer  than 
will  any  silicate,  and  there  are  some  restorations  in  anterior  teeth 
that  may  be  more  serviceably  made  with  porcelain  than  with  a 
combination  of  gold  and  sihcate. 

Detail  of  Cavity  Preparation  for  Inlays 

Cavities  in  the  Gingival  Third  of  Labial  or  Buccal  Surfaces. — The 
only  difference  in  the  preparation  of  these  cavities  for  inlays  and 
for  fillings  is  that  for  the  former  the  angle  between  the  axial  wall 
and  the  surrounding  walls  is  made  slightly  less  sharp.  If  the 
cavity  is  wider  at  the  axial  wall  than  at  the  dento-enamel  margin 
it  will  be  manifestly  impossible  to  fit  a  matrix  to  it  properly  and 
remove  it  without  warping,  and  yet  the  surrounding  walls  may 
be  made  almost  parallel,  with  very  nearly  a  right  angle  between 

212 


MAKING    INLAY    FILLINGS 


213 


them  and  the  axial  wall.  It  is  the  failure  to  give  these  cavities  a 
definitely  retentive  form  which  is  accountable  for  the  loss  of  many 
inlays.  A  saucer-shaped  cavity  depending  on  the  cement  to  re- 
tain the  inlay  in  place  will  not,  as  has  just  been  indicated,  prove 
effective.  There  is  of  course  a  slightly  increased  difficulty  in  fit- 
ting a  matrix  to  a  deep  cavity  with  angles,  but  it  can  be  done  with 
care  and  patience,  and  the  resultant  sense  of  security  given  the 
inlay  will  well  repay  the  effort.  Figs.  105  and  106  show  a  longi- 
tudinal section  of  an  incisor  with  cavity  cut  for  an  inlay,  and  a 
cross-section  of  the  same  tooth  with  inlay  in  place. 


Fig.  105. 


Fig.  107. 


Fig.  108. 


Cavities  in  the  Proximal  Surfaces  of  Incisors  or  Cuspids. — To 
insert  inlays  in  these  cavities  requires  either  that  the  teeth  must 
be  widely  separated  or  that  the  labial  or  lingual  wall  shall  be  cut 
away  extensively  to  admit  the  inlay  to  place.  For  this  reason 
most  of  these  cases  are  better  met  with  the  silicate  cements  in  all 
conditions  where  gold  would  be  conspicuous. 

Cavities  in  the  Proximal  Surfaces  of  Incisors  Involving  the  Incisal 
Angle. — It  is  here  that  the  porcelain  worker  must  expend  his  very 
best  effort  in  order  to  succeed,  and  yet  it  is  often  in  these  appar- 
ently doubtful  cases  where  the  most  gratifying  results  are  at- 
tained. There  are  two  principal  methods  of  preparing  these  cavi- 
ties, though  variations  may  be  made  from  these  in  accordance 
with  the  particular  form  that  has  been  given  the  cavity  by  decay, 
and  also  the  form  of  the  tooth  itself.  In  teeth  that  are  thick 
labio-lingually  the  labial  enamel  plate  in  the  incisal  region  need 
not  be  cut  away.  The  cavity  may  be  formed  by  cutting  a  step 
such  as  has  already  been  suggested  for  gold  fiUings,  except  that 
the  step  must  be  wider  and  deeper  for  porcelain  than  for  gold 
and  the  angles  not  quite  so  sharp.  In  other  cases  a  step  may  be 
dispensed  with  and  the  cavity  formed  as  illustrated  in  Fig.  107. 
It  will  be  seen  that  in  this  form  of  cavity  the  inlay  can  be  dis- 
placed in  only  one  direction — lingually.     There  is  little  retention 


214  PRINCIPLES    AND    PRACTICE    OF   FILLING    TEETH 

against  dislodgement  in  this  direction,  but  in  the  mouth  we  sel- 
dom find  much  stress  against  an  inlay  to  force  it  lingually,  and 
in  practice  this  form  of  preparation  has  proved  satisfactory. 
Where  the  tooth  is  narrow  labio-lingually  it  will  usually  be 
found  necessary  to  cut  across  the  incisal  end,  as  illustrated  in 
Fig.  108,  involving  the  labial  plate  of  enamel  as  well  as  the 
hngual,  but  of  course  extending  the  step  farther  rootwise  on  the 
lingual  than  on  the  labial  surface.  The  object  is  to  secure  room 
for  appreciable  bulk  of  porcelain.  The  weak  point  of  these  in- 
lays is  where  the  proximal  portion  joins  the  step,  and  in  this  con- 
nection it  will  often  be  found  possible  to  increase  the  strength  of 
the  inlay  by  building  the  porcelain  thicker  toward  the  lingual 
at  this  point  than  the  tooth  originally  was.  In  cases  where  the 
lower  incisor  closes  tight  against  the  lingual  surface  of  the  upper 
this  of  course  cannot  be  done,  unless  the  end  of  the  lower  incisor 
is  ground  off,  but  in  many  cases  it  will  be  noted  that  there  is 
sufficient  space  between  the  lower  tooth  and  the  cavity  in  the 
upper  to  admit  of  an  appreciable  bulk  of  porcelain  without  im- 
pingement. In  the  use  of  porcelain  advantage  should  be  taken 
of  every  possible  means  of  securing  additional  strength  by  in- 
creasing the  bulk  of  the  material,  with  the  idea  ever  in  mind  that 
thin  pieces  of  porcelain  are  easily  broken. 

Fitting  the  Matrix 

Whether  the  matrix  is  to  be  of  platinum  or  gold  the  same  gen- 
eral plan  of  procedure  is  applicable.  If  platinum  is  used  it  should 
be  from  1-1500  to  1-1000  of  an  inch  in  thickness.  For  gold  inlays 
the  ordinary  No.  60  beaten  foil  will  be  found  convenient  for  the 
matrix. 

There  are  two  general  methods  of  forming  the  matrix — one  to 
take  an  impression  of  the  cavity,  make  from  this  a  model,  and 
swage  the  matrix  to  the  model;  the  other,  to  fit  the  matrix  directly 
to  the  cavity  in  the  tooth.  Each  method  claims  its  adherents 
among  inlay-makers  and  each  has  its  advantages  in  certain  cases, 
but  for  general  use  in  the  cavities  where  inlays  are  most  indicated 
it  would  seem  an  unnecessary  expenditure  of  time  and  energy  to 
take  an  impression  of  the  cavity  and  make  a  model.  The 
argument  is  frequently  urged  in  support  of  this  method  that  a 
burnished  matrix  can  never  be  made  to  fit  so  perfectly  as  a  swaged 
matrix,  and  that  therefore  a  model  should  be  made  for  swaging 


MAKING   INLAY   FILLINGS  215 

purposes.  This  argument  can  readily  be  met  by  the  statement 
that  the  most  approved  methods  of  fitting  a  matrix  to  the  cavity 
in^the  mouth  involves  a  system  of  swaging  instead  of  burnishing, 
and;that  we  are  thereby  enabled  to  bring  the  matrix  into  as  close 
relationship  to  the  cavity  without  warping  as  would  be  possible 
on  a  model.  It  is  true  that  the  early  efforts  at  burnishing  the 
matrix  to  the  cavity  with  a  metal  burnisher  were  faulty  in  view 
of  the  tendency  to  warp  the  matrix,  but  this  is  no  longer  necessary. 

Then  again  it  is  possible  for  one  who  is  skillful  to  fit  a  matrix 
perfectly  to  many  cavities  of  which  an  impression  cannot  be 
taken,  and  this  is  particularly  true  of  deep  cavities  formed  with 
the  idea  of  securing  frictional  retention  against  the  walls.  It 
would  seem  on  superficial  observation  that  any  cavity  of  such  a 
form  that  a  matrix  could  be  fitted  to  it  successfully  would  admit 
of  an  impression  being  taken,  but  this  is  not  true.  By  frictional 
retention  is  meant  a  cavity  with  walls  so  nearly  parallel  that  the 
matrix  will  bind  very  slightly  on  removal,  and  in  which  it  requires 
dehcate  manipulation  to  remove  it  without  distortion.  When  the 
inlay  is  made  it  goes  to  place  with  a  snap  on  account  of  a  slight 
binding  from  friction  against  the  walls.  An  impression  of  such  a 
cavity  could  not  be  taken,  but  a  metal  matrix  may  be  fitted  to  it, 
and  with  good  effect  as  to  the  resultant  security  of  the  inlay.  It 
is  a  nice  point  worthy  of  study  in  the  preparation  of  these  cavities 
to  make  the  walls  so  nearly  parallel  that  there  shall  be  no  doubt 
about  the  security  of  the  inlay  when  set,  and  yet  not  make  them 
undercut  in  any  way  to  prevent  the  removal  of  the  matrix.  An- 
other factor  worthy  of  note  in  the  choice  of  methods  is  that  there 
are  many  instances  where  greater  space  is  necessary  between  teeth 
for  the  taking  of  an  impression  than  for  fitting  a  matrix  to  the 
cavity,  and  greater  space  than  is  required  for  the  proper  contour 
of  the  inlay.  And  yet  the  operator  should  be  familiar  with  each 
of  these  methods  so  as  to  be  able  to  employ  either,  as  particular 
cases  may  indicate. 

Taking  an  Impression  of  the  Cavity. — For  those  cases  where 
the  operator  decides  that  he  can  do  better  work  on  a  model  than 
in  the  mouth,  an  impression  of  the  cavity  may  be  taken  in  the 
following  way:  After  the  cavity  is  properly  prepared  it  should  be 
dried  and  freely  dusted  with  soapstone  or  talcum  powder,  rub- 
bing the  interior  well  with  the  powder  by  means  of  a  pellet  of 
cotton  to  prevent  adhesion  of  the  impression  material  to  the 
walls.     Some  quick-setting  cement  should  then  be  mixed  and  a 


216  PEINCIPLES    AND    PRACTICE    OF   FILLING   TEETH 

mass  of  it  rolled  and  kneaded  in  the  fingers,  at  the  same  time 
incorporating  some  of  the  talcum  powder  into  the  surface  of  the 
cement.  This  should  then  be  forced  into  the  cavity  and  a 
sufficient  surplus  used  to  give  a  perfect  outline  of  the  enamel 
margins.  When  hard  it  should  be  gently  lifted  from  the  cavity 
and  properly  trimmed,  leaving  in  all  cases  the  marginal  outlines 
of  the  cavity  well  marked.  A  model  from  this  impression  may  be 
made  with  copper  amalgam,  the  oxyphosphate  of  copper,  or  the 
ordinary  oxyphosphate  of  zinc — the  same  precautions  as  before 
being  necessary  to. prevent  adhesion.  Into  the  model  so  made 
the  matrix  may  be  swaged  by  a  flexible  water-bag  made  for  this 
purpose,  or  by  forcing  it  to  place  with  a  mass  of  unvulcanized 
rubber. 

There  is  one  advantage  of  working  from  a  model:  The  inlay 
during  the  process  of  construction  may  be  carried  to  the  model 
after  each  baking,  and  if  there  has  been  any  change  of  .form  in 
the  matrix  due  to  shrinkage  of  the  porcelain  in  fusing,  it  is  over- 
come by  again  swaging  the  margins  of  the  matrix  to  the  model. 

Adapting  a  Matrix  to  the  Cavity  in  the  Tooth. — A  piece  of  the 
matrix  material,  whether  of  platinum  or  gold,  considerably  larger 
than  the  area  of  the  cavity  should  be  annealed  and  placed  over 
the  orifice  of  the  cavity.  Care  should  be  exercised  in  placing  it  so 
that  when  forced  to  the  bottom  of  the  cavity  there  shall  be  a 
surplus  extending  beyond  the  entire  marginal  outline  of  the 
cavity.  Unless  attention  is  given  to  this  the  matrix  is  liable  to  be 
drawn  more  to  one  side  than  the  other  in  the  early  stages  of  the 
swaging,  leaving  some  one  part  of  the  cavity  outline  uncovered 
by  the  matrix.  For  carrying  the  matrix  to  position  in  the  cavity 
a  pellet  of  wet  cotton  sufficiently  large  to  cover  the  floor  of  the 
cavity  should  be  grasped  in  strong-pointed  pliers  and  very  gently 
forced  in  the  direction  of  the  deeper  portions  of  the  cavity.  If 
this  is  done  carefully  it  will  usually  be  found  possible  to  carry 
the  matrix  to  the  depth  of  the  cavity  without  serious  tearing  of 
the  metal.  When  this  first  pellet  has  been  forced  to  place, 
another  hard-rolled  pellet  should  be  used  to  gently  wipe  the 
curled-up  margins  of  the  matrix  back  toward  the  cavity  margins 
to  get  them  out  of  the  way,  but  under  no  circumstances  should 
there  be  any  attempt  made  to  fit  the  matrix  accurately  to  the 
margins  at  this  stage.  The  object  is  to  secure  a  perfect  adapta- 
tion of  the  matrix  to  the  deeper  parts  of  the  cavity  first.  To  this 
end  wet  cotton  should  be  packed  in,  pellet  after  pellet,  till  the 


MAKING    INLAY    FILLINGS  217 

soggy  mass  is  tightly  wedged  against  the  walls  of  the  cavity,  each 
pellet  being  driven  forcibly  home  with  pluggers  or  burnishers 
having  large  ends.  If  sufficient  cotton  is  kept  in  the  cavity  there 
is  no  tendency  of  the  matrix  to  spring  away  from  one  point  while 
it  is  being  forced  against  another.  In  fact  it  becomes  a  process 
of  swaging  instead  of  burnishing,  and  in  this  connection  it  may  be 
stated  that  it  is  seldom  necessary  or  advisable  to  allow  the  bur- 
nisher to  come  in  contact  with  the  matrix.  All  the  force  should  be 
exerted  upon  the  cotton  and  through  that  to  the  matrix.  When 
the  cavity  is  nearly  full  of  the  cotton  and  the  entire  mass  tightly 
packed  against  the  cavity  walls  an  accurate  fitting  of  the  margins 
of  the  matrix  may  usually  be  obtained  to  better  advantage  with 
a  layer  of  unvulcanis^ed  rubber  than  with  anything  else.  This 
should  be  placed  over  the  cotton  and  with  a  broad  burnisher  the 
rubber  forcibly  compressed  over  the  entire  marginal  outline  of 
the  cavity,  carrying  the  matrix  into  the  closest  possible  adaptation 
to  the  enamel  margin  throughout,  but  having  the  same  care  as 
before  about  letting  the  burnisher  touch  the  matrix.  It  requires 
but  very  little  rubbing  of  the  metal  burnisher  against  the  matrix 
to  harden  it  and  make  it  curl  away  from  the  margin. 

When  the  fitting  has  been  as  accurate  as  possible,  the  rubber 
should  be  removed  and  the  cotton  picked  out  piece  by  piece.  A 
close  scrutiny  can  then  be  given  the  matrix  to  see  if  the  adapta- 
tion is  good  and  the  cavity  margins  sharply  outlined.  If  there 
seems  any  defect  or  failure  of  adaptation  the  process  of  swaging 
should  be  repeated  before  the  matrix  is  removed  from  the  cavity, 
the  object  being  to  make  the  one  insertion  of  the  matrix  answer 
the  purpose  instead  of  repeatedly  removing  it  and  inserting  it. 
The  less  handling  the  matrix  receives  outside  the  cavity  the  safer 
it  is,  and  frequently  the  attempt  to  place  it  back  in  the  cavity 
after  it  has  been  once  removed  injures  its  form  and  prevents  as 
perfect  an  adaptation  as  it  was  capable  of  receiving  in  the  first 
instance. 

When  assurance  is  had  that  the  matrix  is  satisfactory  in  fit  it 
should  be  very  gently  teased  out  of  the  cavity  by  placing  a  sharp 
exploring  instrument  under  the  free  margin  which  extends  beyond 
the  cavity,  and  at  some  point  opposite  a  place  in  the  cavity  where 
on  account  of  its  form  the  matrix  would  naturally  be  expected  to 
yield  readily.  A  little  adroitness  and  delicacy  of  manipulation 
will  usually  result  in  loosening  the  matrix  and  lifting  it  from  the 
cavity  without  marring  it  or  changing  its  form. 


218  PKINCIPLES    AND    PEACTICE    OF    FILLING    TEETH 

In  cases  where  contour  work  is  to  be  done  the  matrix  should  be 
made  to  lap  the  cavity-margins  sufficiently  to  give  an  outline  of 
the  surrounding  surfaces  as  a  guide  in  building  the  inlay  to  the 
proper  contour. 

Porcelain  Bodies 

The  question  of  the  most  suitable  body  for  use  in  porcelain  in- 
lays has  been  quite  extensively  discussed  by  the  profession,  and 
there  seems  to  be  much  diversity  of  opinion  as  to  whether  a  low- 
fusing  or  a  high-fusing  body  is  indicated.  By  high-fusing  body 
is  meant  a  porcelain  which  fuses  at  a  temperature  above  the 
melting-point  of  pure  gold,  thus  demanding  platinum  as  a 
matrix,  while  a  low-fusing  body  is  one  which  may  be  fused  upon  a 
gold  matrix.  The  chief  contention  made  by  the  advocates  of 
the  latter  is  that  a  gold  matrix  may  be  more  readily  fitted  to  a 
cavity  than  one  of  platinum,  and  therefore  a  low-fusing  body  is 
preferable,  but  with  the  careful  preparation  now  given  to  the 
manufacture  of  platinum  for  this  purpose  there  is  really  not  suffi- 
cient difference  between  the  two  materials  to  furnish  a  tangible 
argument. 

In  the  past  it  has  been  found  that  the  color  of  the  low-fusing 
bodies  has  not  proved  sufficiently  stable  to  withstand  the  fluids  of 
the  mouth,  nor  has  it  been  so  easy  to  obtain  the  exact  shade  in 
fusing.  The  character  of  the  coloring  material  in  these  bodies  is 
such  that  the  least  overheating  beyond  the  precise  point  of  fusing 
is  Hable  to  burn  out  the  color  and  leave  a  bleached  effect.  For 
these  reasons  it  would  seem  best  to  confine  ourselves  chiefly  to 
high-fusing  porcelain.  The  question  of  personal  equation  enters 
into  the  manipulation  of  porcelain,  and  some  operators  will  find 
one  kind  of  porcelain  more  manageable  than  another.  The  proper 
course  to  pursue  is  to  test  personally  the  different  kinds,  and 
select  that  which  seems  most  serviceable  for  each  individual  case. 

Before  an  operator  attempts  porcelain  inlay  work  in  the  mouth 
he  should  make  himself  familiar  with  the  management  of  porce- 
lain bodies  both  in  relation  to  the  method  of  baking  and  the  con- 
trol of  shades,  and  this  can  only  be  attained  by  actual  experimen- 
tation with  the  material  itself. 

Matching  Shades 

There  can  be  no  set  rule  given  for  the  matching  of  shades  in  the 
wide  variations  encountered  in  the  mouth,  though  any  dentist  of 


MAKING    INLAY    FILLINGS  219 

fine  artistic  sense  can  obtain  very  satisfactory  results  by  a  close 
study  of  the  problem  with  the  aid  of  the  shade  guides  furnished 
for  this  purpose  by  the  porcelain  makers.  Dr.  W.  T.  Reeves, 
of  Chicago,  has  given  some  very  useful  suggestions  along  this 
line  which  it  will  be  well  for  the  inlay  worker  to  study.  The 
basis  of  his  method  of  shading  lies  in  the  fact  that  the  human 
enamel  is  more  or  less  transparent  and  that  therefore  the  shades 
of  the  teeth  are  regulated  by  the  underlying  tissue.  In  view  of 
this  Dr.  Reeves  suggests  that  the  basal  shades  of  any  particular 
tooth  to  be  matched  should  be  baked  into  the  foundation  body  of 
the  inlay,  and  a  nearly  transparent  enamel  body  of  lower  fusing- 
point  than  the  foundation  baked  over  this  to  complete  the  inlay. 

There  are  many  little  knacks  of  blending  colors  to  match  differ- 
ent shades  which  the  observant  operator  will  soon  acquire,  and 
the  more  this  fascinating  subject  is  studied  the  more  its  pos- 
sibilities open  up.  There  are  certain  positions  in  the  mouth 
which,  on  account  of  the  manner  in  which  the  light  strikes  them, 
render  it  almost  impossible  to  simulate  true  enamel,  and  yet  the 
effect  with  a  well-made  porcelain  inlay  is  never  so  conspicuous 
as  with  a  metallic  filling. 

It  will  be  found  that  the  varying  shades  of  a  tooth  from  the 
gum-margin  to  the  incisal  edge  must  be  distinctly  recognized  to 
get  the  best  results,  and  there  is  one  practical  point  in  this  connec- 
tion worth  recording.  Where  an  inlay  is  to  be  made  for  a  labial 
cavity  in  the  gingival  third  of  the  tooth  the  shade  selected  should 
be  somewhat  darker  than  would  seem  suitable  when  matching  it 
with  the  shade  guide.  This  is  in  accordance  with  the  fact  that 
the  teeth  usually  deepen  in  color  as  they  approach  the  gum,  and 
it  is  particularly  applicable  to  cuspids  for  another  reason.  When 
standing  immediately  in  front  of  a  patient  the  labial  surface  of  a 
cuspid  is  so  presented  to  the  observer  that  the  Kght  readily  passes 
through  the  inlay  so  as  to  make  it  appear  translucent  and  lighter 
in  color  than  it  really  is.  It  will  be  found  that  there  is  a  great 
difference  in  the  appearance  of  one  of  these  convex  inlays  in  a 
cuspid  when  viewed  from  different  positions.  An  inlay  which 
may  seem  perfect  in  match  when  the  operator  is  standing  a  little 
to  one  side  so  as  to  look  directly  against  the  labial  convexity  of 
the  tooth  will  appear  much  too  light  when  he  steps  around  to  the 
other  side  of  the  patient  and  views  it  diagonally  across  the  labial 
surface.  The  shade  should  be  so  arranged  as  to  give  the  best 
results  at  conversational  distance  from  the  patient  in  the  varying 


220  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

lights  and  shadows  which  play  about  the  mouth,  and  this  can 
usually  be  done  by  selecting  the  darker  shades  for  this  region 
of  the  tooth. 

If  porcelain  is  used  in  proximal  surfaces  the  shade  should  be  a 
trifle  lighter  than  seems  necessary.  It  is  not  objectionable  to 
have  an  inlay  in  this  region  a  shade  too  white  where  it  passes 
into  the  shadow  between  the  teeth,  but  if  it  is  in  the  least  degree 
too  dark  it  is  at  once  conspicuous. 

Baking  the  Porcelain 

The  time  required  for  fusing  porcelain  depends  on  the  kind  of 
furnace  and  the  grade  of  porcelain,  and  instructions  in  this  regard 
are  given  by  the  manufacturers,  but  for  the  mixing  and  manipula- 
tion of  the  material  a  few  practical  points  may  be  mentioned. 
Absolute  cleanliness  is  the  cardinal  requisite  in  handling  por- 
celain. The  matrix  should  be  perfectly  clean  and  free  from  saliva 
or  blood.  The  porcelain  slab,  the  spatulas,  and  the  water  used 
for  mixing  should  also  be  clean.  A  sufficient  amount  of  founda- 
tion body  for  the  case  in  hand  should  be  thoroughly  mixed  with 
water  and  the  floor  of  the  matrix  covered  with  it.  In  case  there 
has  been  a  break  in  the  matrix  in  the  deeper  portions  of  the  cavity 
the  porcelain  will  usually  flow  over  this  without  detriment.  The 
matrix  may  be  handled  by  grasping  the  free  margin  most  distant 
from  the  cavity  with  pliers,  and  when  held  in  this  manner  the 
porcelain  should  be  settled  into  the  matrix  in  such  a  way  that  the 
particles  of  porcelain  are  brought  into  the  closest  possible  relation- 
ship with  each  other,  to  prevent  as  nearly  as  may  be  an  undue 
shrinking  of  the  porcelain  in  fusing.  This  can  be  done  by  rubbing 
a  rough-handled  instrument  of  some  kind  across  the  pliers  which 
hold  the  matrix,  thus  jarring  the  matrix  and  settling  the  particles 
of  porcelain  to  the  bottom  and  bringing  the  water  to  the  top. 
The  surplus  water  may  be  absorbed  with  clean  blotting  paper 
and  the  jarring  continued  till  the  porcelain  is  thoroughly  compact. 
It  should  then  be  dried  further  with  heat  and  passed  to  the 
furnace  and  fused,  the  first  baking  usually  being  carried  only  to 
a  biscuit  and  not  to  a  complete  fusing.  When  the  foundation  is 
thus  laid  the  inlay  is  built  to  full  form  with  the  enamel  body, 
which  latter  should  be  perfectly  fused  to  give  it  a  uniform 
transparent  gloss.  The  number  of  bakings  varies  with  different 
cases — small  inlays  sometimes  being  completed  with  two  bakings. 


MAKING    INLAY    FILLINGS  221 

while  the  more  compUcated  cases  may  require  four  or  five  to  gain 
the  best  results. 

When  the  inlay  is  baked  the  platinum  matrix  should  be  peeled 
away,  leaving  the  porcelain  ready  for  setting.  If  the  form  of 
the  cavity  is  such  that  the  retention  of  the  inlay  is  in  doubt, 
the  cavity  side  of  the  inlay  may  be  grooved  with  a  thin  disk. 
In  any  event  the  glazed  surface  of  the  porcelain  next  the  cavity 
should  be  slightly  ground  with  a  stone,  or  etched  with  hydro- 
fluoric acid,  so  as  to  present  a  better  surface  for  adhesion.  This 
acid  must  be  handled  with  great  care.  It  comes  in  wax  bottles, 
and  when  etching  the  porcelain  all  surfaces  of  the  inlay  except 
the  cavity  side  should  be  covered  with  wax.  In  setting  the 
inlay  the  cavity  should  be  dry  and  the  cement  carefully  mixed 
to  such  a  consistence  that  it  will  require  some  force  to  squeeze 
it  out  from  under  the  inlay,  but  it  should  not  be  so  stiff  that  the 
inlay  cannot  be  driven  perfectly  in  place.  In  forcing  the  inlay 
a  wooden  point  may  be  used,  and  considerable  pressure  should 
be  maintained  on  the  inlay  for  several  minutes  till  the  cement 
begins  to  crystallize,  after  which  the  surplus  may  be  trimmed 
away  and  the  margins  wiped  clean  with  cotton. 

It  will  usually  be  found  that  a  porcelain  inlay  is  not  quite  so 
satisfactory  in  appearance  after  setting  with  the  oxyphosphate 
of  zinc,  as  when  simply  placed  in  the  cavity  preparatory  to 
setting,  and  it  would  be  well  if  we  had  some  translucent  cement 
that  could  be  relied  on  for  this  purpose.  The  silicates  are  an 
improvement  in  appearance,  but  for  setting  inlays  they  are  not 
sufficiently  adhesive  to  make  them  serviceable  except  in  those 
cases  where  there  is  a  decided  undercut. 

Proximo-Occlusal  Cavities  in  Bicuspids  and  Molars  for  Gold  Inlays 

The  first  thing  to  remember  in  the  preparation  of  these 
cavities  for  inlays  is  that  the  proximal  part  must  be  opened 
very  freely  bucco-lingually  as  it  approaches  the  occlusal  sur- 
face. If  possible,  the  buccal  and  lingual  walls  should  diverge 
so  as  to  be  slightly  wider  bucco-lingually  at  the  occlusal  surface 
than  at  the  gingival  margin.  If  the  orifice  of  the  cavity  is 
narrower  than  the  deeper  parts  or  if  there  is  any  overhanging  of 
the  occlusal  enamel  it  will  be  found  impossible  to  properly  fit 
a  wax  model,  and  no  operator  can  successfully  employ  inlays 
in  many  of  these  cases  without  the  will  to  cut  very  extensively 


222  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

for  the  purpose  of  opening  up  the  cavity  for  convenient  access. 
It  is  often  necessary  to  cut  away  much  sound  tooth  tissue  in 
order  to  secure  such  a  form  that  the  inlay  will  go  readily  to  place, 
though  in  some  instances  where  there  is  extensive  penetration 
of  the  decay  leaving  strong  walls  overhanging,  it  is  advisable  to 
clean  out  the  decay  and  fill  the  undercuts  thereby  left  with  ce- 
ment, and  fit  the  wax  over  this. 

In  opening  the  cavity  it  will  usually  be  carried  into  a  fissure  in 
the  occlusal  surface,  which  necessitates  cutting  out  the  fissure  to 
the  end.  This  aids  very  materially  in  giving  the  best  retentive 
form  to  the  inlay.  In  fact,  the  only  certain  method  of  anchoring 
these  inlays  is  to  create  a  step  in  the  occlusal  surface  at  right  an- 
gles with  the  proximal  cavity,  and  so  locking  or  dovetailing  the 
step  portion  that  the  inlay  cannot  possibly  be  tipped  out  of  posi- 
tion in  mastication.  If  these  cavities  are  prepared  properly  there 
is  only  one  way  in  which  an  inlay  can  be  removed,  and  that  is 
toward  the  occlusal.  The  tendency  to  loosen  inlays  in  this  direc- 
tion is  not  great,  though  we  must  not  forget  the  occasional  lifting 
stress  exerted  on  such  an  inlay  by  adhesive  materials  in  the  mouth 
in  the  form  of  sticky  candy,  etc.,  and  we  should  provide  against 
this  by  so  forming  all  of  the  axial  walls  of  the  cavity  that  there 
will  be  some  frictional  retention  when  the  inlay  is  forced  to  place. 

There  are  two  ways  of  producing  an  interlocking  effect  in  the 
step  portion  of  these  cavities,  and  the  operator  must  be  governed 


Fig.  109.  Fig.  110.  Fig.  111. 

by  the  form  of  the  tooth  and  the  penetration  of  decay  as  to  which 
one  he  employs.  He  may  either  widen  the  step  bucco-lingually 
at  its  termination,  as  in  Fig.  109,  or  he  may  deepen  in  rootwise, 
as  in  Fig.  110.  The  former  shows  the  occlusal  surface  of  a  bicus- 
pid with  the  inlay  locked  in  place,  the  latter  a  section  of  a  bicuspid 
with  the  inlay  dipping  into  the  tooth  at  the  termination  of  the 
step.  The  importance  of  producing  this  dovetailed  anchorage  for 
inlays  cannot  be  overstated.  It  is  the  only  certain  means  of  re- 
taining them  securely  against  dislodgement.  In  some  instances 
it  may  be  found  possible  in  molars  where  we  have  considerable 


MAKING    INLAY    FILLINGS  223 

bulk  of  tooth  tissue  to  interlock  the  inlay  by  a  slight  groove  along 
the  buccal  and  lingual  walls  extending  through  to  the  occlusal 
surface,  making  the  axial  wall  somewhat  wider  bucco-lingually 
than  the  cavity  at  the  dento-enamel  margin,  as  suggested  by  Dr. 
R.  Ottolengui.  This  is  only  in  cases  where  the  occlusal  enamel 
is  perfect  and  free  from  fissures,  and  the  cutting  of  a  step  would 
seem  too  radical  a  procedure  (Fig.  111).  In  these  cavities  as  in 
all  others  for  inlay  work  the  operator  must  get  away  from  the  idea 
that  cement  can  be  depended  upon  for  material  retention  of  the 
inlay,  and  the  cavities  must  be  so  formed  that  there  is  depth  of 
inlay  and  frictional  retention  along  the  walls. 

In  preparing  cavities  in  bicuspids  and  molars  much  of  the  cut- 
ting may  be  done  with  stones,  chisels,  and  disks,  and  the  fact  that 
it  is  seldom  necessary  to  apply  the  rubber  dam  for  this  work 
makes  it  less  irksome  to  the  patient.  The  same  general  plan  of 
flat-seats  for  the  inlay  to  rest  on  should  be  followed  as  was 
advocated  for  foil  fillings,  the  chief  difference  between  the  two 
being  that  the  angles  between  walls  be  slightly  less  sharp  for 
inlays. 

Making  Gold  Inlays 

The  fact  that  gold  inlay  work  has  assumed  so  important 
a  place  in  our  practice  makes  it  imperative  that  every  operator 
shall  master  the  details  of  the  process  from  beginning  to  end. 
The  profession  is  under  the  deepest  obligation  to  Dr.  W.  H. 
Taggart  of  Chicago  [for  introducing  the  cast  gold  inlay  in  1907. 
By  this  method  more  satisfactory  results  may  be  obtained  with 
greater  ease  than  by  the  previous  method  of  fitting  a  matrix  to 
the  cavity  and  flowing  gold  into  it;  and  consequently  the  inlay 
to-day  has  been  brought  into  a  much  wider  range  of  usefulness- — to 
the  greater  comfort  of  the  patient  and  dentist  and  a  more  certain 
means  of  saving  many  of  these  teeth.  Much  of  the  technique  out- 
lined in  the  following  pages  has  been  taken  from  Dr.  Taggart's 
teachings. 

After  the  cavity  is  prepared  the  next  step  is  to  make  the  wax 
model.  Various  makes  of  inlay  wax  forms  are  on  the  market  avail- 
able for  the  operator.  A- wax  should  be  selected  with  sufficient 
rigidity  so  that  when  warmed  and  forced  into  the  cavity  and 
removed  it  may  be  held  in  the  fingers  and  carved  without  the 
margins  being  rounded  by  pressure  in  handling. 

A  piece  of  wax  should  be  selected  of  suitable  form  and  size 
to  meet  the  requirements  of  the  cavity,  and  placed  in  water  hot 


224  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

enough  to  soften  the  wax  throughout  the  entire  mass  without 
melting  the  surface.  The  temperature  of  the  water  must  be 
governed  by  the  character  of  the  wax — -some  varieties  softening 
at  a  much  lower  temperature  than  others.  To  get  the  most 
perfect  softening  of ;.  the  wax  throughout  it  should  be  left  in  the 
water  not  too  hot  for  some  time  rather  than  to  use  hotter  water 
for  a  shorter  time.  If  the  wax  is  not  of  a  suitable  form  for  the 
given  cavity  it  may  be  molded  in  the  fingers  after  being  heated 
to  approximate  the  shape  required  before  being  placed  in  the 
cavity.  While  the  wax  is  being  softened  in  the  water  the  Bun- 
sen  burner  on  the  operating  table  should  be  lighted,  so  that 
just  before  carrying  the  wax  to  the  cavity  it  may  be  held  near  the 
flame  for  a  moment  to  soften  the  immediate  surface,  thus  giving  a 
sharper  outline  of  the  cavity  margins  when  the  wax  is  forced  to 
place.  The  point  of  the  wax  form  should  be  placed  into  the 
cavity  in  such  a  way  if  possible  as  to  have  it  impinge  on  the  deep- 
est part  or  floor  of  the  cavity  before  the  sides  bind  much  so  that 
there  is  certainty  of  perfect  adaptation  to  the  deeper  surfaces 
of  the  cavity.  This  relates  particularly  to  the  gingival  wall  in 
proximo-occlusal  cavities.  With  the  ball  of  the  thumb  or  finger 
over  the  wax  the  entire  mass  should  be  forced  with  firm  pressure 
into  every  portion  of  the  cavity  till  it  squeezes  out  over  all 
margins.  Then  the  patient  should  be  instructed  to  bite  into 
the  wax  and  make  a  movement  of  the  jaws  as  in  mastication. 
If  this  lateral  motion  is  not  insisted  on  and  there  is  only  the 
straight  up  and  down  bite,  it  will  be  found  that  when  the  inlay 
is  made  and  the  process  of  mastication  exerted  on  it  certain 
points  will  impinge  against  the  occluding  tooth. 

After  the  patient  has  chewed  on  the  wax  in  this  way  it  should 
be  gently  lifted  from  the  cavity  by  passing  the  pliers  under  some 
of  the  overhanging  surplus  mass  outside  the  cavity.  In  this 
way  the  wax  may  be  taken  from  the  cavity  without  distort- 
ing it.  Then  with  a  small  pen-knife  the  surplus  wax  may  be 
trimmed  away  from  the  proximal  part  of  the  model  down  to 
near  the  cavity  margins  and  the  wax  slipped  back  in  the  cavity. 
When  seated  in  place  the  wax  may  be  smoothed  down  flush 
with  the  cavity  margin  over  the  entire  proximal  portion  with  thin 
bladed  trimmers  or  in  some  instances  with  fine  tape.  The 
occlusal  surface  may  be  carved  to  reproduce  the  sulci  and  other 
anatomical  markings  with  any  instrument  which  most  appeals 
to  the  operator,   a  very  excellent  one  for  this  purpose  being 


MAKING   INLAY   FILLINGS 


225 


that  devised  by  Dr.  P.  J.  Puterbaugh,  Fig.  112.  Care  should 
be  taken  in  this  carving  process  to  make  the  model  distinctively- 
anatomical  so  that  the  inlay  will  prove  of  the  greatest  service 
in  mastication.  Sometimes  much  of  this  carving 
may  be  done  out  of  the  mouth,  holding  the  wax  in 
the  fingers.  After  the  carving  instrument  has  been 
used  and  the  model  replaced  in  the  cavity,  a  still 
finer  and  smoother  surface  may  be  given  the  wax 
by  wiping  it  over  with  a  small  pellet  of  cotton  held 
in  pliers  and  smeared  with  vaseline.  In  this  way 
the  highest  polish  may  be  given  the  wax  and  the 
model  left  so  smooth  that  when  the  cast  is  made 
there  will  be  very  little  finishing  necessary.  Extra 
time  spent  in  preparing  the  wax  in  this  way  will  be 
compensated  for  in  the  saving  of  time  in  finishing 
the  gold.  After  the  wax  is  satisfactory  in  every 
particular,  the  anatomical  lines  well  defined,  the 
margins  cleanly  cut  against  the  enamel  and  flush 
"'  with  it,  and  the  surface  polished  so  as  to  glisten, 

it  may  then  be  removed  from  the  cavity  by  insert- 
ing the  point  of  an  exploring  instrument  into  it  at 
some  convenient  place  and  lifting  it  out.  The  end 
of  the  sprue  wire  from  the  cap  on  the  investment 
ring  should  be  heated  in  the  flame  and  carefully 
forced  into  the  wax  at  some  point  away  from  the 
margins.  With  proximo-occlusal  inlays  this  should 
usually  be  at  the  contact  point.  A  heated  bur- 
nisher should  be  deftly  passed  around  the  sprue  just 


Fig.  112. 


Fig.  113. 


touching  the  wax  sufficiently  to  attach  the  sprue  securely.  The 
other  end  of  the  sprue  should  be  slipped  into  the  hole  made 
for  this  purpose  in  the  cap  of  the  casting  ring,  when  the  inlay  is 

15 


226 


PRINCIPLES   AND    PRACTICE    OF   FILLING    TEETH 


ready  for  the  investment,  Fig.  113.     The  cavity  should  be  sealed 
with  gutta  percha  till  the  next  sitting. 

Investing  the  Wax. — -Various  investments  for  inlays  have  been 
placed  upon  the  market,  some  of  them  so  perfect  that  they  leave 
little  to  be  desired.  The  profession  is  fortunate  that  in  this 
cast  inlay-work  the  technique  and  materials  have  been  worked 
out  very  completely,  chiefly,  be  it  said,  by  Dr.  Taggart  himself. 
The  most  satisfactory  investment  is  one  which  is  quite  fluid 


Fig.   114. 


when  mixed  in  proper  proportions  with  water,  which  does  not 
set  too  quickly,  which  is  sufficiently  hard  when  set  to  withstand 
the  force  necessary  for  casting,  and  which  will  not  shrink  when 
dried  out  and  heated.  The  Taggart  investment  fulfils  these 
requirements  in  a  high  degree,  and  its  uniform  working  qualities 
render  it  a  very  satisfactory  material  for  this  purpose. 

This  investment  should  invariably  be  mixed  with  exact  pro- 
portions of  water  and  material,  and  to  this  end  a  measuring 
balance  is  provided  with  the  investment,  Fig.  114,  the  large  end 


Fig.  115. 


to  be  filled  with  the  material  and  the  small  end  with  water.  For 
mixing,  a  large  rubber  bowl  should  be  used  with  a  thin  flexible 
spatula,  the  bowl  being  tipped  slightly  on  its  side  and  the  broad 
blade  of  the  spatula  wiped  back  and  forth  through  the  invest- 
ment. When  the  mix  seems  uniform  the  spatula  should  be  laid 
aside  and  the  bowl  taken  in  the  hand.  Fig.  115,  and  tipped  a 
trifle  and  jarred  on  the  bench  all  the  while  revolving  the  bowl  so 


MAKING    INLAY   FILLINGS  227 

the  investment  keeps  well  spread  over  the  inner  surface  of  the 
bowl.  This  process  should  be  kept  up  for  two  or  three  minutes 
so  that  every  vestige  of  air  bubbles  will  be  removed.  This  leaves 
the  investment  in  the  best  possible  condition  for  use.  The  wax 
model  should  previously  have  been  thoroughly  cleaned  with  a 
camel's  hair  brush  and  alcohol  or  acetone  and  dried.  The  invest- 
ment should  be  painted  over  the  entire  surface  of  the  wax  with  a 
small  camel's  hair  brush  having  only  a  few  hairs,  so  that  the  in- 
vestment is  carried  into  every  inequality  of  the  inlay  without 
the  possibility  of  leaving  air  bubbles  around  the  wax.  Then  the 
ring  of  the  mold  is  placed  on  the  cap  and  the  investment  poured 
into  the  mold  letting  it  enter  at  one  side  of  the  wax  model  and 
cover  the  bottom  of  the  mold  first,  flowing  up  to  the  under  side 
of  the  wax  and  finally  enveloping  it  completely.  In  this  way 
the  danger  of  air  bubbles  is  obviated. 

When  the  investment  is  hard  the  surplus  is  scraped  on  a  level 
with  the  ring  and  the  cap  gently  heated  and  taken  off.  This 
leaves  the  sprue  still  remaining  in  the  investment.  It  should  be 
heated,  the  mold  held  upside  down  to 
prevent  any  particles  from  dropping  in 
the  hole  and  the  sprue  pulled  out.  This 
leaves  the  mold  as  shown  in  Fig.  116. 
The  case  should  then  be  placed  over  a 
slow  heat,  with  a  metal  sheet  of  some 
kind  between  the  mold  and  the  flame, 
and  the  wax  melted  out.  The  way  to 
determine  when  the  wax  is  completely 
vaporized  is  by  the  brown  stain  through- 
out the  investment  and  when  no  more 
fumes  arise  from  it.     Up  to  this  point  ^^^-  ^^^■ 

the  process  should  be  carried  on  consecutively  step  by  step,  not 
permitting  the  mold  to  He  around  the  office  for  any  time  after 
being  poured  and  before  melting  out  the  wax,  but  after  the  wax 
is  taken  out  the  mold  may  remain  indefinitely  before  the  cast  is 
made.  Dr.  Taggart  advises  casting  in  a  cold  mold,  claiming 
more  uniformly  perfect  results,  and  yet  if  there  is  lack  of  time 
the  gold  may  be  cast  immediately  after  the  wax  is  vaporized. 

Gold  for  Casting. — Pure  gold  probably  gives  the  most  perfect 
results  in  a  cast  inlay,  and  in  positions  where  there  is  not  much 
wear  upon  the  inlay  it  may  be  used.  But  an  inlay  of  pure  gold 
if  subjected  to  much  stress  will  soon  take  on  a  roughened  and 


228 


PRINCIPLES    AND    PRACTICE    OP    FILLING    TEETH 


scratched  surface  due  to  its  softness.  The  most  acceptable  gold 
for  ordinary  use  in  inlay  work  is  22  Karat  gold,  which  makes  a 
satisfactory  cast,  and  is  sufficiently  hard  to  withstand  the  usual 
stress  of  mastication. 

Casting.— Various  methods  of  casting  gold  inlays  have  been 
devised  since  the  introduction  of  the  process  by  Dr.  Taggart, 
but  it  is  safe  to  say  that  no  improvement  has  been  made  over  the 
one  originated  by  him.     This  is  by  a  pressure  machine,  Fig.  117, 


using  compressed  nitrous  oxid  gas  for  pressure,  and  also,  in 
connection  with  illuminating  gas,  for  heat.  This  combination 
makes  an  intensely  hot  flame  which  will  melt  gold  very  quickly. 
The  pressure  may  be  regulated  perfectly  to  a  definite  number  of 
pounds,  and  recorded  by  a  gauge.     Usually  about  eight  pounds 


MAKING    INLAY    FILLINGS  229 

for  ordinary  work  will  be  ample,  and  this  amount  of  force  will 
not  in  any  way  distort  the  mold  with  the  investments  in  common 
use  to-day.  In  melting  the  gold  it  should  be  carried  beyond  the 
melting  point  till  it  begins  to  quiver  under  the  heat,  when  it  is 
in  the  most  finely  divided  and  best  state  to  cast.  After  the 
handle  is  thrust  down  on  the  mold  with  a  sharp  jerk,  it  should 
be  held  at  least  thirty  seconds  till  the  gold  has  begun  to  chill, 
when  it  may  be  taken  out  and  cooled.  Sufl&cient  surplus  of 
gold  should  be  used  so  that  when  the  casting  is  made  it  leaves  a 
good  sized  button  of  gold  attached  to  the  inlay.  After  being 
made  as  clean  as  possible  by  brushing  and  scraping  off  the 
attached  investment  material,  the  inlay  may  be  held  over  the 
flame  for  a  short  time  and  dropped  into  hydrofluoric  or  sulphuric 
acid,  to  remove  all  clinging  investment  particles.  It  should 
then  be  thoroughly  rinsed  and  brushed  with  water. 

In  cutting  off  the  surplus  button  at  the  contact  point  it  is 
always  well  not  to  cut  too  near  the  inlay,  but  to  leave  the  gold 
quite  prominent  at  this  point.  The  reason  for  this  is  that  we 
always  want  a  full,  rounded  and  very  tight  contact  point  on  the 
inlay — one  which  will  necessitate  some  force  to  drive  the  inlay 
to  place  in  the  cavity.  Every  inlay  in  a  proximal  surface  in  order 
to  give  the  greatest  integrity  to  the  arch  in  this  region  should 
go  to  place  with  some  difficulty,  and  exert  a  wedging  force 
between  the  teeth  which  will  at  first  be  complained  of  by  the 
patient.  Assurance  may  be  given  with  full  confidence  that  this 
wedged  sensation  will  invariably  pass  away  in  a  short  time.  The 
reason  why  we  need  this  small,  rounded  and  tight  contact  has 
already  been  explained  in  considering  the  interproximal  space 
and  contact  point,  and  as  has  been  intimated  it  is  one  of  the 
chief  virtues  of  the  inlay  that  by  its  use  we  may  tighten  up  loose 
contacts  in  the  easiest  possible  manner.  If  the  inlay  had  noth- 
ing else  to  recommend  it,  it  would  have  this  one  supreme  virtue 
that  it  enables  us  to  prevent  the  wedging  of  food  between  teeth, 
and  to  guard  the  integrity  of  the  interproximal  space  more 
certainly  and  conveniently  than  by  any  other  means  at  our 
command.  This  tightening  of  the  contact  is  beneficial  not  alone 
to  the  tooth  being  treated  but  it  snugs  up  the  contacts  of  the 
adjacent  teeth  and  strengthens  the  arch  in  that  entire  region. 
It  is  hoped  that  the  profession  will  more  and  more  study  the 
significance  of  the  interproximal  space  and  the  contact  point, 
and  that  they  will  come  to  recognize  to  a  greater  degree  the 


230  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

possibilities  of  their  normal  maintenance  through  the  medium 
of  the  inlay.  In  some  mouths  where  the  wear  on  the  proximal 
surfaces  of  the  teeth  is  very  great  as  shown  by  wide  facets  on  the 
enamel  and  on  fillings  it  is  well  to  make  the  contact  point  on  the 
inlay  harder  than  22  Karat  gold.  The  proximal  portion  of  the 
inlay  in  the  vicinity  of  the  contact  may  be  ground  away  and  some 
18  Karat  gold  solder  melted  on  with  the  blowpipe.  This  when 
rounded  will  make  a  good  wearing  surface. 

No  matter  how  perfect  a  casting  may  come  from  the  mold  it 
is  always  improved  by  going  over  it  with  a  rotary  tool  like  a 
stone  or  disk,  and  this  should  be  done  before  trying  the  inlay 
in  the  cavity.  The  cavity  side  of  the  inlay  also  needs  attention. 
In  view  of  the  fact  that  inlays  are  sometimes  lifted  out  of  the 
cavity  in  biting  into  sticky  materials  like  taffy  candy,  it  is  always 
well  to  provide  as  much  as  possible  against  this  lifting  stress  by 
grooving  the  inlay  wherever  possible.  In  proximo-occlusal  inlays 
this  may  be  done  by  cutting  a  groove  with  a  thin  knife-edge  stone 
bucco-lingually  along  the  proximal  part  of  the  inlay  on  the  cavity 
side,  which  will  allow  the  cement  to  flow  into  it  and  hold  the  inlay. 
In  occlusal  inlays  there  is  usually  some  point  where  a  groove  may 
be  cut  between  the  pulpal  wall  and  the  occlusal  surface.  It  is 
also  well  at  other  points  to  roughen  the  cavity  side  of  the  inlay 
with  a  graver  so  that  the  cement  may  have  a  better  hold.  The 
inlay  should  not  be  polished  before  being  fitted  to  the  cavity, 
and  the  occlusion  tested.  Occasionally,  even  with  the  best 
possible  carving  of  the  wax,  it  will  be  found  that  the  occluding 
tooth  will  strike  the  inlay  too  hard  at  certain  points  and  these 
should  be  noted  and  ground.  When  all  is  satisfactory  the  inlay 
may  be  polished  and  cemented. 

Cementing  the  Inlay. — The  cement  best  suited  for  sealing  inlays 
in  a  cavity  is  one  which  has  the  powder  ground  quite  fine,  and 
which  will  set  under  moisture.  It  should  be  mixed  very  care- 
fully drawing  small  portions  of  the  powder  into  the  liquid  and 
incorporating  each  portion  thoroughly  before  adding  any  more. 
It  is  a  nice  point  to  get  the  mix  of  the  proper  consistency — 
guarding  against  the  danger  of  having  it  so  thick  that  the  inlay 
can  not  be  perfectly  seated  or  so  thin  that  it  is  worthless.  The 
operator  should  study  the  behavior  of  the  particular  cement 
he  selects,  and  be  able  to  gauge  the  consistency  to  a  nicety. 

In  forcing  the  inlay  to  place  whether  in  the  initial  trial  or 
when  cementing  it,  the  best  results  are  to  be  obtained  by  using 


MAKING    INLAY    FILLINGS  231 

a  heavy  soft  mallet  like  a  lead-and-leather  mallet  and  driving  it 
to  position  with  a  plugger.  In  some  instances  good  seating  of 
the  inlay  may  be  obtained  by  placing  over  the  occlusal  surface 
of  the  inlay  after  it  has  been  malleted  some  unvulcanized  rubber 
and  instructing  the  patient  to  bite  upon  it  with  considerable 
force.  One  important  thing  must  be  remembered  at  this  point. 
If  the  inlay  is  a  proximal  one,  every  particle  of  the  surplus 
cement  must  be  removed  from  the  interproximal  space  before 
it  becomes  thoroughly  set.  This  surplus  cement  squeezes  out 
over  the  gingival  margin  of  the  cavity  and  lodges  against  the 
proximal  surface  of  the  inlay,  and  if  permitted  to  remain  it 
proves  to  be  as  much  of  an  irritant  as  so  much  calculus  would  be. 
If  not  removed  at  once  it  is  sometimes  very  difficult  to  flake 
it  off  later. 

Even  though  the  inlay  has  been  polished  out  of  the  mouth 
it  will  usually  be  found  necessary  to  go  over  the  margins  after 
it  has  been  cemented,  and  dress  the  gold  perfectly  flush  with  the 
enamel.  This  can  be  done  with  fine  stones  or  with  disks  in  the 
engine,  but  these  should  not  be  used  till  the  cement  is  sufficiently 
set  so  that  the  slight  jarring  of  the  rotary  appliance  will  not 
disturb  it.  The  disk  should  invariably  be  played  over  the  sur- 
face in  such  a  way  that  it  passes  from  the  gold  to  the  enamel, 
thus  spinning  the  gold  tight  over  the  cavity  margin. 

Direct  and  Indirect  Methods  of  Making  Inlays 

The  method  just  outlined  is  called  the  ''direct  method"  where- 
by the  wax  is  fitted  to  the  cavity  in  the  tooth.  Some  operators 
prefer  what  is  known  as  the  ''indirect  method,"  taking  an  im- 
pression of  the  cavity,  making  a  model  and  fitting  the  wax  for 
the  inlay  to  the  model.  It  is  a  matter  of  individual  preference 
as  to  which  method  is  used,  it  having  been  demonstrated  beyond 
a  doubt  that  excellent  results  may  be  obtained  by  either  method. 
There  is  no  question  that  for  the.  large  majority  of  operators 
the  direct  method  is  preferable  owing  to  the  fewer  number  of 
technical  procedures  necessary,  and  the  consequent  saving  of 
time.  Then  again  this  fact  must  not  be  ignored,  that  in  mul- 
tiplying the  number  of  processes  there  is  increased  danger  of 
admitting  errors  and  it  may  safely  be  said  that  with  the  same 
care  and  skill  in  the  daily  run  of  our  work  more  perfect  results 
may  be  obtained  by  the  direct  than  by  the  indirect  method. 


232  PRINCIPLES    AND    PRACTICE    OF   FILLING    TEETH 

With  an  operator  who  makes  his  own  inlays  the  saving  of  time 
by  the  direct  method  is  very  appreciable,  but  where  an  assistant 
is  employed  to  make  the  inlays  all  the  operator  himself  has  to  do 
is  to  take  an  impression  of  the  cavity,  with  a  bite,  turn  it  over 
to  his  assistant  and  receive  back  the  finished  inlay.  The  matter 
of  personal  equation  enters  into  this  question  as  with  many  others 
in  dentistry,  and  each  operator  must  select  that  method  by  which 
he  can  secure  the  best  results. 

In  taking  an  impression  of  the  cavity  the  method  already 
indicated  for  porcelain  inlays  may  be  used,  or  a  good  modeling 
compound  which  will  give  sharp  margins  may  be  employed, 
and  the  articulating  model  made  in  the  usual  way. 

General  Considerations. — A  difficulty  that  is  sometimes  en- 
countered with  inlays  is  that  the  inlay  when  cast  does  not  always 
fit  the  cavity  margins  perfectly.  Whether  this  is  due  to  the  fact 
that  the  inlay  binds  at  some  point  and  does  not  go  fully  to  place 
or  to  a  shrinkage  of  the  gold  during  the  casting  process,  it  is 
sometimes  difficult  to  determine.  A  careful  examination  should 
be  made  of  the  cavity  side  of  the  inlay  to  see  if  there  are  any 
bubbles  or  other  unevenness  which  might  hold  the  inlay  from  being 
properly  seated,  and  if  any  are  found  they  should  be  removed 
before  trying  to  place  the  inlay. 

The  most  difficult  inlays  to  make,  and  secure  perfect  margins 
are  in  those  extensive  restorations  in  molars  which  involve  the 
mesial,  occlusal  and  distal  surfaces — called  for  brevity  the  m-o-d- 
cavities.  Frequently  it  will  be  found  that  with  these  inlays  the 
gold  will  not  fit  down  snugly  to  one  or  both  of  the  gingival  margins 
of  the  cavity.  Before  concluding  that  this  is  due  to  shrinkage 
of  the  gold  at  this  point  it  is  well  to  examine  carefully  the  cavity 
side  of  the  inlay  as  it  passes  over  the  occlusal  surface.  Any 
binding  or  riding  of  the  inlay  at  this  point  will  hold  it  up  and 
prevent  proper  seating.  But  undoubtedly  there  are  many  cases 
of  shrinkage  in  these  large  inlays,  and  the  closest  attention  should 
be  given  to  the  technic  of  casting  to  avoid  this  as  much  as  possible. 
Probably  the  best  results  may  be  obtained  in  these  cases  by 
using  pure  gold  and  hardening  the  contact  points  with  18  Karat 
solder. 

Another  precaution  relates  to  the  cavity  preparation,  and  the 
placing  of  the  sprue  in  casting.  The  gingival  margins  of  these 
cavities  should  be  quite  freely  beveled  so  that  at  this  point  they 
will  form  a  lap  joint  instead  of  a  butt  joint.     When  the  inlay  is 


MAKING    INLAY    FILLINGS  233 

seated  even  if  there  has  been  a  slight  shrinkage  the  thin  edge  of 
gold  over  the  lap  may  be  burnished  down  tight  to  the  margin  and 
seal  it.  In  placing  the  sprue  into  the  wax  it  should  be  inserted 
in  the  occlusal  surface  midway  between  the  mesial  and  distal 
surfaces.  If  placed  at  one  of  the  contact  points,  any  shrinkage  of 
the  gold  will  result  in  a  very  perceptible  change  in  the  form  of  the 
gingival  portion  of  the  inlay  most  remote  from  the  sprue  attach- 
ment and  cause  it  to  draw  away.  With  the  sprue  in  the  center 
of  the  filling  the  pressure  on  the  gold  in  casting  is  more  evenly 
distributed  throughout  the  mass  with  less  likelihood  of  material 
change. 

Occasionally  an  inlay  will  come  from  the  mold  with  the  margins 
rounded  and  unfit  for  use — the  casting  not  having  been  perfect — 
and  in  other  cases  the  gold  does  not  cast  at  all.  Sometimes  the 
surplus  button  of  gold  will  be  found  separated  completely  from 
the  inlay  in  the  mold.  These  vagaries  happen  in  cases  where 
the  technical  procedures  have  apparently  been  carried  out  in 
precisely  the  same  way  as  usual.  With  our  present  knowledge 
they  cannot  always  be  accounted  for,  but  as  we  study  more 
and  more  this  most  fascinating  process  of  casting  gold  inlays 
we  shall  clear  up  these  apparent  inconsistencies  and  place  the 
work  on  a  more  stable  basis.  And  in  this  connection  let  it  be 
said  that  the  profession  owes  it  to  itself  and  the  people  it  serves 
that  it  shall  give  the  same  painstaking  study  to  master  the  prin- 
ciples and  conquer  the  details  of  the  process — in  other  words,  to 
properly  standardize  it — as  has  so  cheerfully  been  given  to  other 
lines  of  practice  such  for  instance  as  cavity  preparation,  inserting 
gold  foil,  etc.  When  this  is  done  the  work  will  have  a  very  wide 
range  of  usefulness  and  prove  one  of  the  greatest  blessings  the 
profession  has  ever  had. 


CHAPTER  XVII 
PULP-CAPPING 

When  decay  has  penetrated  a  tooth  sufficiently  to  reach  the 
pulp,  the  problem  arises  as  to  whether  an  attempt  shall  be  made 
to  save  the  pulp  by  capping  or  whether  it  shall  be  destroyed 
and  the  canal  filled.  The  question  is  one  which  calls  for  dis- 
criminating judgment  on  the  part  of  the  operator  and  a  careful 
study  of  the  peculiar  manifestations  presented  in  the  individual 
case.  No  set  rule  can  be  formulated  as  a  guide  under  all  condi- 
tions, but  the  most  prominent  indications  for  or  against  pulp- 
capping  may  be  pointed  out  in  the  way  of  suggestion  to  the 
observant  operator. 

The  chief  considerations  relate  to  the  age  of  the  patient,  the 
extent  of  exposure,  the  location  in  the  mouth  of  the  affected  tooth, 
and  the  duration  and  degree  of  the  pain  caused  by  the  exposure. 
In  young  patients  the  prospect  of  saving  a  pulp  alive  is  greater 
than  in  aged  patients,  and  the  necessity  is  also  more  urgent. 
A  pulp  is  never  through  with  its  active  functional  duty  till  the 
tooth  is  completely  calcified  to  the  very  apex  of  the  root,  and  this 
does  not  take  place  till  after  the  eruption  of  the  crown  through 
the  gum.  In  fact,  teeth  may  erupt  and  take  on  the  carious 
process  to  the  extent  of  pulp-exposure  before  the  apex  of  the 
root  is  formed,  and  if  there  is  death  of  the  pulp  at  this  stage  the 
apex  is  left  unformed,  and  the  problem  of  saving  the  tooth  is 
greatly  complicated.  It  becomes  important,  then,  in  all  cases 
of  pulp-exposure  in  young  patients  to  attempt  to  save  the  pulp 
till  the  process  of  calcification  is  complete,  and  while  teeth  may 
vary  in  different  mouths  in  regard  to  the  age  of  complete  calcifica- 
tion, it  may  be  said  in  a  general  way  to  be  about  six  years  after 
they  begin  to  erupt.  The  fact  that  pulps  may  more  successfully 
be  saved  during  youth  is  another  argument  in  favor  of  making 
the  attempt,  the  reason  for  this  being  that  the  apical  openings 
in  the  roots  are  larger,  which  gives  greater  play  for  the  engorge- 
ment of  the  vessels  of  the  pulp  without  injury.     As  age  advances 

234 


PULP-CAPPING  235 

the  apical  openings  become  smaller,  and  a  very  slight  irritation 
of  the  pulp  may  cause  its  death. 

The  extent  of  the  exposure  is  also  an  important  factor.  If 
the  pulp  is  only  slightly  exposed  and  has  not  been  injured  in  any 
way,  or  if  it  has  been  accidentally  uncovered  by  an  excavator, 
the  chances  of  saving  it  are  greater  than  where  the  exposure  is 
large  and  the  pulp  thereby  subjected  to  all  the  dangers  of  infec- 
tion. One  of  the  chief  elements  of  success  in  pulp-capping 
relates  to  the  avoidance  of  pressure  on  the  pulp,  and  in  large 
exposures  this  is  more  difficult. 

The  question  of  location  in  the  mouth  refers  to  teeth  that  are 
exposed  to  view  in  contradistinction  to  teeth  so  situated  that 
they  are  never  seen  in  ordinary  conversation — the  difference 
being  that  with  the  former  a  greater  effort  should  be  made  to 
save  the  pulp  than  with  the  latter.  The  reason  for  this  is  that 
on  death  of  the  pulp  there  is  usually  a  tendency  for  the  tooth 
to  become  more  or  less  discolored  and  lose  its  normal  trans- 
lucency — sometimes  to  the  extent  of  being  unsightly  and  con- 
spicuous. The  fact  that  by  proper  management  from  the  time 
the  pulp  is  destroyed  to  the  final  filling  of  the  cavity  any  seiious 
discoloration  may  ordinarily  be  avoided  does  not  alter  the  general 
proposition  that  the  most  conservative  practice  involves  the 
saving  of  pulps  in  such  teeth  if  possible.  An  operator  is  never 
able  to  predict  with  certainty  that  a  pulpless  tooth  will  per- 
manently retain  its  color  even  under  the  best  treatment,  and 
it  may  therefore  be  considered  a  legitimate  procedure  to  make  the 
attempt  at  pulp-preservation  in  many  of  these  cases  even  where 
the  chances  are  against  it.  There  is  a  wide  variation  in  the 
tenacity  of  life  exhibited  in  dijEferent  pulps,  and  if  there  is  a 
reasonable  promise  that  the  pulp  may  be  saved  in  one  of  the 
anterior  teeth  it  should  be  given  the  benefit  of  the  doubt  and 
treated  accordingly.  But  the  operator  should  invariably  protect 
his  reputation  by  a  straightforward  statement  of  the  facts  in 
the  case  to  the  patient,  and  a  plain  disavowal  in  advance  of  any 
responsibility  in  the  event  of  the  pulp  dying  under  the  capping. 
If  patients  are  at  all  intelligent  they  will  appreciate  an  operator's 
efforts  on  their  behalf,  and  will  not  hold  him  blameworthy  if 
the  issue  turns  out  amiss.  With  patients  who  are  not  reasonably 
disposed  the  operator  would  better  take  no  chances,  but  pro- 
ceed to  destroy  all  pulps  where  there  is  doubt  of  their  preserva- 
tion.    Patients  of  this  type  are  not  entitled  to  the  same  consid- 


236  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

eratioia  in  this  particular  that  are  those  with  a  due  regard  for  the 
necessary  Hmitations  of  human  nature  on  the  part  of  the  dentist, 
and  who  are  charitably  inclined  in  the  face  of  seemingly  unfavor- 
able results. 

A  most  important  consideration  bearing  on  the  decision  as  be- 
tween capping  and  destruction  of  the  pulp  relates  to  the  length  of 
time  the  pulp  has  been  inflamed,  and  the  degree  of  the  inflam- 
matory process.  The  most  apparent  index  to  this  is  the  concur- 
rent pain.  If  a  tooth  has  ached  violently  from  an  exposed,  or 
nearly  exposed,  pulp,  and  particularly  if  this  high  degree  of  in- 
flammation has  continued  for  many  hours,  the  conclusions  are 
that  the  pulp  has  been  so  profoundly  affected  that  it  cannot  re- 
cover, and  the  attempt  to  save  it  will  be  fruitless.  But  if  the 
pulp  has  been  brought  under  treatment  in  the  early  stages  of  the 
inflammatory  process,  and  especially  if  it  yields  promptly  to 
palliative  treatment,  the  promise  is  greater  that  it  may  be  saved. 

The  question  of  the  general  health  of  the  patient  must  not  be 
overlooked  in  relation  to  its  bearing  on  the  probable  success 
or  failure  of  pulp-capping,  nor  must  we  lose  sight  of  the  influence 
of  locality.  In  some  regions — particularly  in  malarial  districts — 
the  attempt  to  save  exposed  pulps  is  said  to  invariably  result  in 
failure.  Repeated  experiences  of  this  nature  have  often  led 
men  who  were  ordinarily  careful  and  conservative  to  make  the 
statement  that  wherever  a  pulp  becomes  actually  exposed  the 
only  legitimate  line  of  treatment  is  to  proceed  to  its  destruction, 
but  in  view  of  the  well-established  fact  that  pulps  have  lived 
to  do  good  service  for  many  years  after  being  capped,  this  must 
be  considered  extreme  teaching.  The  pulp  is  too  useful  under 
certain  conditions — which  have  already  been  indicated — to  justify 
an  operator  in  following  so  radical  a  procedure. 

Pulp-capping,  like  many  other  lines  of  practice,  must  be  studied 
with  care  and  entered  into  with  discriminating  judgment.  The 
operator  must  not  expect  success  in  every  case,  even  among  those 
which  seem  most  favorable,  but  the  fact  that  he  has  failures 
should  not  deter  him  from  an  honest  effort  to  do  the  utmost  limit 
for  his  patient  in  those  cases  where  the  preservation  of  the  pulp 
seems  desirable. 

One  important  consideration  in  this  connection  appears  to  have 
been  largely  overlooked  by  practitioners,  viz.,  the  effect  on  the 
pericemental  membrane  following  destruction  of  the  pulp.  It 
will  be  found  in  cases  of  pulpless  teeth,  even  when  there  is  no  ap- 


PULP-CAPPING  237 

parent  discomfort  and  where  the  patient  makes  no  complaint  of  the 
tooth,  that  there  is  never  the  same  resisting  force  in  the  membrane 
that  was  present  when  the  pulp  was  alive.  In  other  words,  a 
patient  can  never  bite  down  upon  a  pulpless  tooth  with  the  same 
degree  of  force  that  is  possible  on  a  tooth  with  a  living  pulp,  and 
while  this  may  never  be  noticeable  in  ordinary  mastication,  yet 
it  impHes  an  impairment  of  the  membrane  which  should  not  be 
ignored  as  a  factor  in  estimating  the  desirability  or  undesirability 
of  saving  a  pulp  or  destroying  it. 

Then  again  the  tendency  in  recent  years  on  the  part  of  many 
medical  men  and  also  many  dentists  to  attribute  a  number  of  the 
physical  ailments  of  humanity  to  metastastic  infection  from 
pulpless  teeth,  such  as  heart  lesions,  arthritis,  neuritis,  etc., 
should  warn  the  dentist  not  to  destroy  pulps  without  good 
cause.  He  has  a  sufficient  problem  on  his  hands  in  the  manage- 
ment of  teeth  that  come  to  him  with  the  pulps  already  dead  with- 
out inviting  more  trouble  by  needlessly  adding  to  the  number. 
Pulps  in  the  past  have  been  destroyed  altogether  too  freely. 
With  many  dentists  there  has  been  little  hesitation  in  devi- 
taUzing  pulps  on  the  slightest  pretext.  If  there  was  the  least 
uncertainty  as  to  saving  a  pulp  it  was  at  once  destroyed,  with 
the  remark  that  "dead  pulps  tell  no  tales."  This  no  longer 
holds  true — indeed  it  never  did.  If  we  are  to  believe  emphatic 
evidence,  dead  pulps  do  tell  some  very  sad  and  disastrous  tales, 
and  the  fewer  pulpless  teeth  we  have  in  a  mouth  the  better.  This 
question  of  infection  from  teeth  which  have  lost  their  pulps  will 
be  considered  in  greater  detail  in  a  subsequent  chapter. 

Materials  for  Capping  Pulps 

Various  materials  have  been  suggested  for  capping  pulps,  each 
advocate  claiming  for  his  especial  material  peculiar  virtues  not 
found  in  the  others.  The  fact  that  one  operator  will  use  a  certain 
material  with  a  greater  degree  of  success  than  another,  while  the 
second  will  employ  a  different  material  to  greater  advantage  than 
the  first,  is  only  another  illustration  of  the  ever-present  factor  of 
personal  equation.  We  cannot  eliminate  this  factor  from  con- 
sideration in  any  Hne  of  practice,  and  in  the  capping  of  pulps  that 
method  and  that  material  which  proves  most  successful  in  the 
hands  of  a  given  operator  should  be  the  method  and  material  for 
him  to  adhere  to. 


238  PEINCIPLES    AND    PEACTICE    OF   FILLING    TEETH 

And  yet  it  may  be  well  to  consider  in  brief  some  of  the  various 
materials  most  commonly  advocated  for  this  purpose.  The  chief 
requisite  of  an  ideal  material  is  the  ability  to  protect  the  pulp 
against  external  irritation.  It  should  therefore  be  a  poor  con- 
ductor of  thermal  changes,  and  should  in  itself  be  a  non-irritant, 
and  plastic  in  nature,  so  that  when  applied  to  the  pulp,  adap- 
tation without  pressure  may  be  attained,  the  mass  subsequently 
crystallizing  into  a  rigid  covering  to  the  pulp  to  protect  it 
against  external  impact. 

Gutta-percha  has  sometimes  been  advocated  as  a  pulp-capping. 
It  has  the  advantage  of  being  a  perfect  non-conductor,  and  it  is 
also  non-irritating  in  character,  but  the  very  nature  of  the  ma- 
terial is  such  that  it  cannot  well  be  accurately  adapted  to  an  ex- 
posed pulp  without  the  danger  of  causing  pressure.  Neither  can 
it  be  depended  on  to  remain  of  uniform  bulk  after  insertion,  and 
the  slight  expansion  which  often  takes  place  in  gutta-percha  may 
act  as  a  mechanical  irritant  to  the  pulp.  It  is  therefore  seldom 
indicated  for  this  purpose — the  factor  of  pressure  being  a  very 
serious  one  to  consider  in  connection  with  pulp-capping. 

To  avoid  undue  pressure  some  operators  employ  a  thin  concave 
metal  disk,  placing  the  disk  over  the  pulp  with  its  concavity 
toward  the  pulp  and  the  rim  of  the  disk  resting  on  the  dentin 
around  the  point  of  exposure,  and  then  jflowing  cement  over  this. 
A  limitation  to  this  plan  would  seem  to  be  the  space  left  between 
the  disk  and  the  pulp.  Nature's  proverbial  abhorrence  of  a 
vacuum  cannot  be  excluded  from  consideration  in  this  operation, 
and  the  aim  should  invariably  be — adaptation  without  pressure. 

The  oxychlorid  of  zinc  has  also  been  advocated  as  a  pulp-cap- 
ping, but  its  strong  irritating  properties  would  seem  to  limit  its  use 
to  those  pulps  which  will  tolerate  a  high  degree  of  irritation  with- 
out dying  under  it.  Some  pulps  are  apparently  able  to  live  under 
severe  irritation  and  are  thereby  stimulated  to  throw  out  a  deposit 
of  secondary  dentin  to  protect  themselves,  but  most  pulps  if  sub- 
jected directly  to  the  irritating  influence  of  oxychlorid  of  zinc 
will  probably  die  as  the  result.  The  fact  that  the  operator  cannot 
predict  with  any  degree  of  assurance  just  which  pulps  will  stand 
irritation  and  which  will  not,  renders  the  use  of  oxychlorid  a 
rather  hazardous  practice. 

The  oxyphosphate  of  zinc  has  probably  claimed  more  advocates 
than  any  other  one  material,  it  being  less  irritating  than  the  oxy- 
chlorid and  very  convenient  to  use.     It  can  be  flowed  over  an 


PULP-CAPPING  239 

exposed  pulp  so  as  to  gain  adaptation  without  pressure,  and  it 
becomes  sufficiently  hard  to  adequately  protect  the  pulp  from  ex- 
ternal force.  But  even  the  oxyphosphate  is  somewhat  irritating — 
so  much  so  to  some  pulps  that  it  is  doubtful  practice  to  place  the 
material  in  direct  contact  with  an  exposure.  To  overcome  this 
irritating  action  a  most  excellent  plan  is  to  first  make  a  paste  by 
mixing  the  powder  of  the  cement  with  some  oil  of  cloves  and  place 
a  thin  layer  of  this  over  the  point  of  exposure  before  inserting  the 
oxyphosphate.  This  paste  will  effectually  protect  the  pulp  from 
the  irritating  influence  of  the  cement,  and  it  is  also  anodyne  in  its 
action  and  a  good  antiseptic.  This  combination  of  materials  if 
skillfully  employed  will  probably  save  any  pulp  that  can  be  saved, 
and  it  will  prove  of  great  comfort  to  the  patient  from  the  fact 
that  it  may  be  employed  without  causing  the  slightest  pain.  In- 
stead of  the  oil  of  cloves  paste,  some  operators  use  a  solution  of 
gutta-percha  dissolved  in  chloroform  to  form  a  film  over  the  pulp 
before  applying  the  oxyphosphate  of  zinc,  but  most  pulps  do  not 
take  so  kindly  to  this  as  to  the  paste.  Dr.  J.  P.  Buckley  rec- 
ommends a  paste  made  by  mixing  oil  of  cloves  with  calcium 
phosphate  in  which  is  incorporated  thymol  (2  per  cent.). 

Method  of  Capping  Pulps 

The  first  requisite  of  success  is  to  remove  all  deleterious  matter 
in  the  immediate  neighborhood  of  the  pulp  by  excavating  the  de- 
calcified and  infected  dentin  as  completely  as  may  be  short  of 
wounding  the  pulp.  The  less  of  this  infiltrated  mass  that  is  left 
in  the  cavity  the  less  the  danger  of  pulp-infection,  as  already 
pointed  out  in  a  previous  chapter.  The  fluids  of  the  mouth 
should  be  carefully  excluded  from  the  cavity  during  the  cleaning 
and  subsequent  capping,  and  nothing  allowed  to  enter  except 
what  the  operator  places  there  himself.  The  cavity  should  first 
be  flooded  with  a  non-irritating  antiseptic,  preferably  the  oil  of 
cloves,  and  after  wiping  out  the  surplus  with  absorbent  cotton  the 
layers  of  decalcified  dentin  may  be  peeled  off  with  a  sharp  spoon 
excavator.  When  the  cleaning  is  complete  the  cavity  should 
again  be  flooded  with  the  antiseptic  and  allowed  to  remain  three 
or  four  minutes  while  the  capping  material  is  being  prepared. 
When  the  paste  is  ready  the  surplus  antiseptic  should  be  removed 
from  the  cavity  with  absorbent  cotton  and  the  paste  carried  to 
position  over  the  pulp.     This  may  be  done  most  expeditiously 


240  PRINCIPLES    AND    PRACTICE    OF   FILLING    TEETH 

with  a  small  pellet  of  tightly  rolled  cotton  in  the  pliers.  As  soon 
as  the  paste  is  gently  patted  to  place  and  the  surplus  removed, 
the  oxyphosphate  of  zinc  may  be  adjusted  over  it  and  allowed  to 
become  hard.  If  it  is  a  case  where  there  seems  much  doubt 
about  the  final  saving  of  the  pulp,  it  is  well  not  to  insert  a  per- 
manent filling  at  this  time.  The  entire  cavity  may  be  filled  with 
the  oxyphosphate  of  zinc  and  the  case  dismissed  for  six  months. 
If  at  the  end  of  that  time  the  pulp  is  found  alive  and  has  given  no 
trouble  a  portion  of  the  cement  filling  may  be  removed  and  re- 
placed by  a  metal  filling,  leaving  sufficient  of  the  oxyphosphate 
over  the  pulp  to  protect  it. 


CHAPTER  XVIII 
DESTRUCTION  OF  THE  PULP 

In  case  it  is  deemed  inexpedient  to  attempt  to  save  a  pulp,  the 
necessity  devolves  upon  the  operator  of  destroying  it  and  filling 
the  canal.  The  most  common  method  of  killing  a  pulp  is  to  make 
an  appHcation  of  arsenic  to  it.  This  may  be  used  in  the  form  of 
an  arsenical  paste  prepared  especially  for  the  purpose  by  manu- 
facturers, to  be  sealed  in  the  cavity  for  a  longer  or  shorter  length 
of  time  as  the  circumstances  indicate.  Another  method  of  pulp- 
destruction  relates  to  forcing  a  solution  of  cocain  or  novocain  into 
the  pulp  by  pressure,  and  removing  the  pulp  at  the  same  sitting. 

The  choice  of  methods  must  be  governed  by  the  necessities  of 
the  case  in  hand,  and  also  by  the  relative  success  which  each  op- 
erator may  experience  with  the  different  methods.  Some  operators 
claim  a  vastly  greater  success  with  pressure  anesthesia  than  with 
arsenic,  while  others  do  not  find  it  in  the  least  satisfactory.  In  a 
general  way  it  may  be  suggested  that  whenever  the  operator  is  not 
pressed  for  time  in  the  removal  of  the  pulp,  he  will  obtain  more 
uniformly  satisfactory  results  from  arsenic  than  from  pressure 
anesthesia,  while  in  an  emergency  case  where  the  immediate  re- 
moval of  the  pulp  is  imperative,  he  will  do  well  to  employ  the 
latter  method.  Recently  an  objection  has  been  raised  against 
arsenic  on  the  ground  that  so  irritating  a  drug  was  hable  to  cause 
trouble  at  the  apex  of  the  root,  and  lead  to  subsequent  infection. 
It  has  yet  to  be  proved  that  the  judicious  use  of  arsenic  will  lead 
to  any  such  result.  The  chief  argument  against  it  has  been 
built  up  from  X-ray  evidence — the  fact  that  a  rarefied  area  being 
found  around  the  apices  of  many  of  these  teeth  having  been 
taken  as  a  proof  of  infection,  A  rarefied  area  is  not  evidence  of 
infection  at  all.  Pulpless  teeth  frequently  exhibit  it  no  matter 
what  the  cause  of  the  death  of  the  pulp  may  have  been — it 
having  been  noted  where  pressure  anesthesia  was  employed,  and 
where  the  pulp  has  died  as  the  result  of  exposure  without  the 
application  of  any  drugs.  Arsenic  has  been  used  to  advantage  too 
many  years  to  be  suddenly  cast  aside  on  mere  assumption  and 
16  241 


242  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

on  X-ray  evidence  alone.     Used  judiciously  it  is  capable  of 
excellent  service  with  relative  safety. 

Destroying  the  Pulp  with  Arsenic 

The  prime  requisite  in  the  application  of  arsenic  for  pulp 
destruction  is  to  so  securely  seal  it  in  the  cavity  that  it  cannot  by 
any  means  ooze  out  and  come  in  contact  with  the  gums.  Arsenic 
is  exceedingly  destructive  to  the  tissues,  and  if  it  reaches  the 
gums  or  other  soft  parts  it  will  destroy  them  over  a  greater  or 
lesser  area,  dependent  upon  the  amount  of  arsenic  and  the  length 
of  time  it  is  allowed  to  come  in  contact  with  them,  often  impli- 
cating the  alveolar  process  in  the  destruction.  This  neces- 
sitates the  most  careful  sealing  of  the  agent  in  the  cavity,  and  to 
accomplish  this  without  causing  pressure  upon  the  pulp  is  often 
a  delicate  procedure.  Much  of  the  pain  in  pulp-destruction  that 
has  been  laid  at  the  door  of  arsenic  is  probably  due  to  pressure  in 
its  application. 

The  two  materials  most  effective  in  sealing  arsenic  are  gutta- 
percha and  cement,  the  former  to  be  used  in  those  cases  where  it 
can  be  adapted  to  the  surrounding  walls  of  the  cavity  with- 
out causing  pressure  toward  the  pulp,  and  the  latter  in  all 
cases  where  the  application  of  gutta-percha  is  diflficult.  Cement 
may  be  gently  flowed  over  the  arsenic  and  made  to  adhere  per- 
fectly to  cavity  walls  without  pressure  on  the  pulp,  and  it  is  there- 
fore preferable  in  most  cases,  its  chief  drawback  being  the  tend- 
ency in  some  instances  where  there  is  not  much  bulk,  for  the 
arsenic  to  penetrate  it  and  cause  soreness  of  the  tongue  or  lips. 
It  is  always  better  in  these  cases  to  melt  paraffin  into  the  surface 
of  the  cement  with  a  heated  instrument  after  the  cement  is 
partially  set.  In  proximal  cavities  where  the  cavity-wall 
slopes  from  the  point  of  exposure  toward  the  gingival  margin  in 
such  a  way  as  to  present  an  incline  down  which  the  arsenic  may 
easily  be  forced  in  applying  the  cement,  the  danger  to  the  gum  in 
the  interproximal  space  is  very  great.  An  operator  may  readUy 
force  some  of  the  arsenic  into  the  space  ahead  of  the  cement  with- 
out being  aware  of  it  till  serious  injury  results.  To  avoid  any 
possible  danger  of  this  nature,  it  is  advisable  in  every  instance 
where  arsenic  is  to  be  applied  to  a  proximal  cavity  to  first  build  a 
layer  of  gutta-percha  over  the  gingival  wall  of  the  cavity  lea,ding 
from  near  the  point  of  exposure  down  to  the  gingival  margin  of 
the  cavity,  and  across  the  interproximal  space  against  the  proxi- 


DESTRUCTION    OF    THE    PULP  243 

mating  tooth  (Fig.  118).  If  this  bridge  of  gutta-percha  be 
thus  constructed  with  care  before  the  arsenic  is  applied,  the  opera- 
tor need  have  no  fear  of  trouble.  In  these  cases  it  is  well  to  use 
cement  over  the  arsenic,  allowing  it  to  extend  against  the  proxi- 
mating  tooth.  It  can  be  applied  under  the  cucumstances  with 
less  danger  of  pressure  than  gutta-percha,  and  it  is  not  so  com- 
pressible under  mastication,  and  therefore  less  liable  to  be  forced 
into  the  cavity  so  as  to  impinge  on  the  pulp. 

The  amount  of  arsenical  paste  required  to  destroy  a  pulp  is  very 
small.  Most  operators  use  altogether  more  than  is  necessary,  and 
thereby  increase  to  that  extent  the  danger  of 
injury  to  the  surrounding  parts.  A  minute 
quantity,  one-half  or  even  one-fourth  the  size 
of  the  head  of  an  ordinary  pin,  if  brought  in 
immediate  contact  with  the  pulp  or  near  it  will 
be  found  ample  for  its  destruction.  A  very 
convenient  method  of  applying  it  is  to  first  ^^^   ^^^ 

place  the  required  amount  on  a  porcelain  slab, 
and  then  with  the  cavity  ready  for  its  reception  a  small  pellet  of 
cotton  moistened  in  the  oil  of  cloves  may  be  used  to  pick  up 
the  paste  and  carry  it  to  the  pulp.  Let  the  paste  be  laid  imme- 
diately over  the  exposure,  ind  then  release  the  pellet  of  cotton 
so  that  it  remains  in  the  cavity  with  the  paste.  Cement  may 
then  be  flowed  over  this  without  danger  of  pressure.  If  this  is 
dexterously  accomplished  there  is  seldom  any  appreciable  pain 
from  the  application. 

Dr.  Burton  Lee  Thorpe  in  the  Dental  Review  for  July,  1917, 
suggests  for  pulp  devitalization  the  following:  "Take  arsenious 
acid,  ground  fine,  IJ^  grams,  powdered  cocain  hydrochlorate  2}4 
grams,  campho-phenique  liquid  to  make  a  creamy  paste.  When 
applied  on  a  very  small  clean  pledget  of  cotton  and  sealed  with 
temporary  cement  in  a  dry  cavity  for  48  hours  invariably  the 
tooth  pulp  will  be  devitalized.  If  any  sensitiveness  should  by 
chance  remain  in  the  pulp  a  second  apphcation  of  24  hours  is 
indicated.  I  have  had  excellent  and  painless  success  with  this 
preparation  for  fifteen  years." 

Dr.  Garrett  Newkirk  offers  a  suggestion  as  originally  advocated 
by  the  late  Dr.  G.  V.  Black  of  adding  a  small  amount  of  lamp- 
black to  the  arsenical  paste  so  that  it  may  be  more  readily  distin- 
guished in  color  from  the  tooth,  and  thus  applied  with  greater 
accuracy. 


244  PRINCIPLES   AND    PRACTICE    OF    FILLING    TEETH 

The  length  of  time  necessary  for  the  arsenic  to  remain  may  be 
judiciously  varied  in  different  cases.  In  young  patients  where 
the  apical  foramina  are  large,  and  in  all  cases  where  for  any  reason 
there  may  be  doubt  about  the  security  of  the  sealing  agent,  the  ar- 
senic should  be  removed  at  the  end  of  twenty-four  hours,  but  it 
is  seldom  advisable  to  attempt  the  removal  of  the  pulp  at  this 
time.  While  the  arsenic  may  have  effectually  accomplished  its 
purpose  so  far  as  the  ultimate  destruction  of  the  pulp  is  con- 
cerned, it  will  ordinarily  be  found  that  sensation  persists  for  some 
days  after  the  application.  In  fact,  it  is  usually  best  to  wait  a 
week  or  ten  days  before  removing  the  pulp,  to  give  ample  time 
for  the  pulp  to  sever  its  connection  at  the  apical  foramen.  Until 
disintegration  takes  place  at  this  point  there  is  always  more  or 
less  sensation  on  its  removal,  and  never  the  same  certainty  of  a 
thorough  removal  to  the  apex.  If  the  attempt  is  made  to  extract 
the  pulp  while  it  is  still  adherent  at  the  apex,  there  is  always 
danger  of  tearing  the  pulp  into  shreds  and  leaving  a  portion  of 
it  in  the  canal.  Decomposition  and  infection  seldom  follow 
immediately  on  the  destruction  of  the  pulp  where  it  is  carefully 
sealed  from  the  fluids  of  the  mouth,  so  that  it  may  safely  be  left 
a  sufficient  time  to  insure  its  painless  removal.  In  every  instance 
where  the  arsenic  is  removed  at  the  end  of  twenty-four  hours,  a 
non-irritating  antiseptic  should  be  placed  over  the  pulp  and  the 
cavity  sealed  with  gutta-percha  till  the  pulp  is  ready  for  removal. 
Under  no  circumstances  should  the  fluids  of  the  mouth  be  allowed 
to  enter  the  cavity  after  the  application  of  the  arsenic. 

In  the  teeth  of  adults  where  for  any  reason  the  patient  cannot 
conveniently  return  in  twenty-four  hours,  and  where  the  sealing 
may  be  made  secure,  it  is  permissible  to  leave  the  arsenic  in  for 
one  week,  at  the  end  of  which  time  the  pulp  may  be  removed 
painlessly.  In  leaving  arsenic  in  for  this  length  of  time  the  great- 
est care  must  be  exercised  in  sealing  it,  and  only  the  minutest 
quantity  of  arsenic  used. 

There  is  always  the  remote  danger  in  the  use  of  arsenic  that 
the  tooth  may  be  lost  through  a  peculiar  accident  whereby  the 
pericemental  membrane  is  destroyed  without  any  leaking  of  the 
arsenic  from  the  cavity  to  the  gum.  This  is  probably  due  to  the 
presence  in  such  cases  of  a  tributary  canal  leading  from  the  pulp- 
canal  proper  through  the  side  of  the  root.  In  any  event  such 
cases  have  been  reported  where  the  arsenic  was  left  in  the  tooth 
only  twenty-four  hours,  but  fortunately  they  are  very  rare — so 


DESTRUCTION    OF    THE    PULP  245 

much  so  that  when  compared  with  the  very  general  use  of  arsenic 
for  pulp-destruction,  they  may  be  considered  only  in  the  light 
of  the  remotest  contingency. 

Removing  the  Pulp  with  Pressure  Anesthesia 

The  occasional  accidents  from  the  use  of  arsenic,  together  with 
the  length  of  time  necessary  for  its  action,  have  led  many  opera- 
tors to  seek  other  means  for  removing  the  pulp.  Probably  the 
best  method  is  to  force  a  solution  of  cocain  or  novocain  into  the 
pulp  to  destroy  its  sensibility,  and  then  extract  it.  This  may  be 
done  by  taking  some  of  the  crystals  of  the  material  and  making 
a  solution  by  adding  a  drop  or  two  of  alcohol  or  chloroform,  and 
gathering  this  up  on  a  small  pellet  of  cotton  and  placing  directly 
over  the  pulp.  Pressure  is  then  applied  to  this  in  such  a  way  as 
to  force  the  solution  into  the  pulp  by  taking  a  mass  of  unvulcan- 
ized  rubber  sufficient  to  fill  the  entire  cavity,  and  with  a  broad- 
ended  instrument  driving  this  toward  the  pulp.  The  pressure 
should  be  gentle  at  first  and  gradually  increased  as  the  pulp  will 
tolerate  it  till  a  very  vigorous  pumping  is  possible,  sufficient  to 
force  the  solution  well  into  the  pulp.  If  the  exposure  is  slight, 
it  may  be  necessary  to  make  a  preliminary  application  in  this 
way  before  the  operator  can  secure  a  broad  enough  exposure  to 
carry  the  solution  well  into  the  pulp-tissue. 

This  method  of  pulp-destruction  seems  in  some  instances  to 
work  almost  like  magic,  the  pulp  evidently  yielding  at  once  to  the 
influence  of  the  anesthetic  to  such  a  degree  as  to  permit  of  its 
removal  without  the  slightest  disturbance  to  the  patient.  But 
in  many  other  cases  the  results  are  wholly  unsatisfactory.  It  is 
notorious  that  cocain  does  not  act  uniformly  in  all  cases,  and  this 
particular  use  of  cocain  seems  to  be  no  exception.  With  som^^e 
patients  the  attempt  to  force  cocain  into  a  pulp  in  this  manner  is 
accompanied  with  most  excruciating  pain,  no  matter  how  geritly 
the  operator  may  work,  nor  how  patient  he  may  be  in  waitihg 
for  the  preliminary  effect  of  the  drug.  In  other  cases  the  most 
strenuous  effort  of  the  operator  fails  entirely  in  producing  anes- 
thesia of  the  pulp,  the  solution  seemingly  having  no  effect  what- 
ever. Another  minor  limitation  of  the  method  relates  to  the 
free  flow  of  blood  following  the  removal  of  the  pulp  under  these 
conditions.  It  is  sometimes  difficult  to  stop  the  flow  so  as  to  get 
the  canal  in  perfect  condition  for  the  reception  of  the  root-filling. 
It  will  also  be  found  that  in  many  cases  following  this  kind  of 


246 


PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 


treatment  a  disagreeable  soreness  develops  in  the  tooth,  lasting 
several  days,  though  seldom  resulting  in  anything  more  serious 
than  a  temporary  discomfort.  This  occurs  oftener  under  this 
method  than  where  the  pulp  has  been  destroyed  with  arsenic 
and  removed  in  the  ordinary  way. 

Removal  of  the  Pulp 

The  operation  of  removing  the  pulp,  whether  it  has  been  de- 
stroyed with  arsenic  or  by  pressure  anesthesia,  is  sometimes  a 


Fig.  119. 


i 
12      3        4 

Fig.   120. 


Fig.  121. 


difficult  one,  particularly  in  small  and  tortuous  canals.  In  the 
larger  canals  which  contain  an  appreciable  mass  of  pulp-tissue 
the  problem  is  much  simplified  by  the  ready  admission  of  a 
barbed  broach  or  an  Ivory  spiral  broach  (Figs.  119  and  120). 
The  latter  in  a  canal  of  sufficient  size  to  admit  it  will  grasp  the 
pulp  and  engage  it  more  securely  than  will  a  barbed  broach — 
the  barbs  sometimes  exhibiting  a  tendency  to  tear  through  the 
pulp-tissue  and  fall  short  of  extracting  it — -but  the  barbed  broach 
will  enter  a  smaller  canal  than  the  spiral  broach  on  account  of  its 
lesser  bulk.  In  this  connection  it  may  be  stated  that  it  is  haz- 
ardous to  introduce  into  any  canal  so  constricted  that  the  broach 
impinges  on  the  canal  walls  while  being  turned,  either  a  barbed 
or  a  spiral  broach. 

The  attempt  to  remove  pulp-tissue  from  constricted  canals 
with  a  barbed  broach  is  accountable  for  many  a  broken  broach, 
and  when  a  piece  of  barbed  broach  is  thus  wedged  into  a  small 
canal  it  is  exceedingly  difficult  to  remove  it. 


DESTRUCTION    OF   THE    PULP  247 

Another  useful  form  of  broach  is  the  Kerr  twist  broach  (Fig. 
121),  which  ma,y  be  used  either  for  the  extraction  of  the  pulp 
or  for  reaming  out  and  cleansing  the  canal. 

Before  attempting  the  removal  of  a  pulp,  the  approaches  to  it 
should  be  opened  up  to  give  the  best  possible  access.  The  roof 
of  the  pulp-chamber  should  be  well  cut  away  so  that  the  chamber 
is  exposed  to  view  and  the  orifices  of  the  canals  accessible.  If  in 
a  molar  the  large  bulbous  portion  of  the  pulp  in  the  chamber  may 
be  scooped  out  with  a  spoon  excavator,  leaving  the  openings  of  the 
canals  exposed.  The  chamber  should  now  be  flooded  with  alco- 
hol and  thoroughly  washed  free  of  debris,  after  which  warm  air 
may  be  used  to  evaporate  the  moisture.  This  drying  out  must 
not  be  carried  sufficiently  far  to  endanger  the  integrity  of  the 
tooth-substance,  the  tendency  being  to  render  teeth  brittle  and 
easily  fractured  when  subjected  to  extended  desiccation.  And 
yet  it  would  be  very  desirable  if  the  operator  could  extract  the 
moisture  from  the  pulp-tissue  before  attempting  its  removal 
from  the  canals.  The  drying  has  a  two-fold  beneficial  effect 
upon  the  pulp — it  lessens  its  bulk  so  as  to  shrink  it  away  from  the 
walls  of  the  canal,  and  it  toughens  it  so  that  it  may  be  more  read- 
ily grasped  and  held  by  the  broach.  In  many  of  these  cases 
where  the  pulp  is  sensitive  to  the  touch  of  the  broach  on  opening 
up  the  chamber,  the  sensitiveness  will  be  found  materially 
reduced  by  desiccation.  A  pulp  under  these  conditions, 
though  sensitive  to  manipulation  by  the  broach,  is  seldom 
sensitive  to  thermal  changes  and  may  therefore  be  dried  with- 
out pain. 

When  the  pulp  is  as  dry  as  practicable,  the  broach  may  be  car- 
ried along  its  side  as  far  into  the  canal  as  it  will  go  and  then  care- 
fully twisted  so  as  to  engage  the  pulp-tissue.  If  a  barbed  broach 
is  being  used,  the  barbed  side  should  be  placed  against  the  wall 
of  the  canal  and  the  smooth  side  in  contact  with  the  pulp- 
tissue  while  it  is  carried  into  the  canal,  and  then  so  turned  that 
the  barbs  grasp  the  pulp  before  its  withdrawal.  For  removing 
pulps  the  broaches,  whether  barbed,  or  spiral,  or  twisted,  should 
be  used  without  handles,  on  account  of  the  greater  facility  with 
which  they  may  be  made  to  enter  the  canal  at  the  desired  angle, 
particularly  in  posterior  teeth.  By  grasping  them  between  the 
thumb  and  index  finger  the  operator  can  direct  them  into  canals 
far  back  in  the  mouth,  and  reach  many  cases  advantageously 
where  a  broach  with  a  handle  could  never  be  made  to  enter  with- 


248  PEINCIPLES    AND    PEACTICE    OF    FILLING    TEETH 

out  curving  it  so  as  to  prevent  a  subsequent  twisting  for  the 
removal  of  the  pulp. 

In  canals  too  small  for  insertion  of  the  barbed  broach — such, 
for  instance,  as  the  buccal  roots  of  upper  molars  and  the  mesial 
roots  of  lower  molars — the  safest  plan  is  to  ream  them  out  with 
the  Best  cleanser.  These  broaches  are  exceedingly  tough  when 
newly  made,  and  almost  any  canal  may  be  advantageously  fol- 
lowed by  them  to  a  point  where  the  constriction  is  so  great  that 
no  broach  will  pass. 

After  the  pulp-tissue  is  removed  from  the  canals  they  should 
be  flooded  with  alcohol  to  wash  out  any  remaining  fragments,  and 
when  thus  cleaned  the  canals  may  be  bathed  in  the  oil  of  cloves  to 
prevent  any  possible  infection,  and  then  flooded  with  alcohol  once 
more  previous  to  the  final  drying  for  the  reception  of  the  root- 
filling.  If  the  pulps  have  been  successfully  removed  and  the 
canals  rendered  clean  and  aseptic,  the  roots  may  be  filled  at  the 
same  setting,  but  where  there  is  any  doubt  it  is  best  to  seal 
ninety-five  per  cent,  phenol  in  the  canal  and  wait  a  week.  Less 
subsequent  soreness  after  filling  is  likely  when  this  is  done. 


CHAPTER  XIX 

FILLING  PULP-CANALS 

The  selection  of  a  suitable  filling-material  for  pulp-canals  is  a 
question  that  has  engaged  the  minds  of  the  profession  ever  since 
pulpless  teeth  have  been  considered  worthy  of  saving.  Without 
going  into  the  history  of  the  various  materials  that  have  from 
time  to  time  been  advocated,  it  is  sufficient  to  say  that  the  most 
universal  practice  to-day  is  to  use  gutta-percha.  This  material 
has  pecuhar  qualities  entitling  it  to  favor  for  this  purpose,  and 
while  it  cannot  be  considered  ideal  in  all  respects  it  probably 
fulfills  the  requirements  to  a  greater  degree  than  any  other  one 
material.  It  is  a  non-conductor  and  a  non-irritant.  It  can  be 
molded  to  fit  the  inequahties  of  any  canal,  and  be  made  to  follow 
a  constricted  and  tortuous  canal,  particularly  if  used  in  the  form  of 
a  solution.  This  solution  is  ordinarily  made  by  dissolving  gutta- 
percha in  chloroform  to  a  cream-like  consistence,  and  then 
pumping  this  into  the  canals,  after  which  a  cone  of  solid  gutta- 
percha is  forced  into  the  canal  to  displace  all  of  the  solution  pos- 
sible and  leave  as  much  as  may  be  of  the  canal  filled  by  solid 
gutta-percha. 

One  limitation  of  the  chloro-percha  solution  consists  in  the  fact 
that  the  chloroform  is  so  readily  evaporated  that  it  is  difficult 
to  keep  the  solution  of  a  proper  consistence  for  daily  use.  To 
provide  a  solution  for  this  purpose  which  will  remain  stationary, 
it  is  suggested  that  when  the  gutta-percha  is  dissolved  in  chloro- 
form and  the  latter  begins  to  evaporate  the  loss  of  fluidity  be 
made  good  by  the  addition  of  eucalyptol.  This  may  be  carried 
on  till  all  the  chloroform  is  gone  and  the  solution  consists  entirely 
of  gutta-percha  and  eucalyptol. 

This  solution  is  to  be  used  not  with  the  idea  of  forming  a  root- 
filling  of  itself,  but  merely  as  a  moistening  agent  for  the  canals 
preparatory  to  the  introduction  of  the  solid  gutta-percha,  which 
latter  will  follow  up  a  canal  to  better  advantage  under  these  con- 
ditions than  if  inserted  in  a  dry  canal. 

249 


250  PRINCIPLES   AND    PRACTICE    OF    FILLING    TEETH 

A  very  excellent  material  for  filling  roots  suggested  by  Dr.  B. 
L.  Cochran,  of  Burlington,  Iowa,  is  made  as  follows:  Base  plate 
gutta-percha  one-half  ounce  in  weight  is  dissolved  in  chloroform. 
Then  a  saturated  solution  of  thymol  in  eucalyptol  one-half  ounce 
by  measure  is  added  to  this  and  mixed  thoroughly.  The  chloro- 
form is  allowed  to  evaporate,  which  leaves  the  preparation  ready 
for  use.  A  small  quantity  is  placed  in  the  pulp  chamber  and 
touched  with  a  warm  broach.  This  immediately  liquefies  it,  and 
it  can  then  be  worked  with  the  broach  into  the  canals.  It  is  ex- 
ceedingly penetrating,  and  may  be  forced  into  the  finest  canals. 
A  gutta-percha  cone  should  be  inserted  into  all  canals  large 
enough  to  admit  one,  and  the  root-filling  made  as  solid  as  possible. 

The  modus  operandi  of  filling  canals  with  gutta-percha  is  to 
pump  the  solution  well  into  the  canals  with  a  smooth  broach, 
and  thereby  displace  the  air  from  the  canals  by  carrying  the 
solution  to  the  apex.  In  constricted  canals  this  pumping  with 
the  broach  should  be  quite  vigorous,  but  in  large  canals  there 
is  not  the  same  necessity  for  extended  manipulation  with  the 
broach,  on  account  of  the  ready  flowing  of  the  solution  to  the 
apex  and  the  subsequent  insertion  of  the  gutta-percha  cone. 
In  fact,  too  much  manipulation  with  the  broach  in  larger  canals 
is  to  be  avoided,  on  account  of  the  possible  danger  from  irri- 
tation beyond  the  apex.  The  aim  should  be  in  these  cases  to 
carry  the  solution  and  the  cone  just  to  the  apex  and  no  farther. 
This  is  often  a  delicate  matter,  but  by  a  close  study  of  these  cases 
the  operator  may  be  reasonably  certain  as  to  the  moment  the  apex 
is  reached.  There  is  no  rule  which  may  be  taught  as  an  infallible 
guide  to  indicate  just  when  this  occurs.  It  has  sometimes  been 
suggested  that  the  evidence  of  an  approach  to  the  apical  foramen 
was  furnished  in  a  flinching  of  the  patient,  but  this  is  by  no  means 
reliable.  In  some  instances  where  the  foramina  are  very  small 
at  the  apex,  and  where  there  is  no  sensitive  tissue  beyond  the 
root,  we  may  secure  a  most  thorough  filling  of  the  canal  without 
the  slightest  sensation  to  the  patient.  To  keep  on  pump- 
ing at  a  case  of  this  kind  looking  for  a  response  from  the  patient 
would  be  mistaken  zeal,  and  might  cause  subsequent  irritation. 
On  the  other  hand,  there  are  cases  where  the  slightest  pressure 
exerted  on  the  contents  of  a  canal,  even  where  the  pressure  is  so  far 
removed  as  the  entrance  to  the  canal  at  the  pulp-chamber,  will 
cause  a  ready  response.  This  may  be  due  to  the  pressure  of  air 
in  the  extremity  of  the  canal,  and  a  response  of  this  kind  would  be 


FILLING    PULP-CANALS  251 

no  indication  whatever  that  the  filling-material  had  reached  the 
apex. 

The  whole  question  is  one  of  intuitive  perception  on  the  part 
of  the  operator,  and  of  such  a  training  of  the  faculties  and  fingers 
that  the  sensation  conveyed  to  the  practitioner  is  the  keynote,  and 
not  the  sensation  conveyed  to  the  patient. 

One  point  in  this  connection  should  be  noted.  In  the  apical 
region  of  most  canals  there  are  small  tributary  canals  which  lead 
off  in  a  delta-like  formation  toward  the  end  of  the  root,  and 
in  many  canals,  particularly  in  flattened  roots  there  are  many 
places  where  the  canal  is  so  constricted  as  to  make  filling  difficult. 
In  all  such  cases  it  requires  much  patience  and  perseverance 
to  work  the  solution  into  these  fine  interstices  and  the  pumping 
motion  with  the  broach  should  be  continued  for  some  time.  The 
late  Dr.  John  R.  Callahan  who  used  a  solution  of  rosin  for  root- 
canal  filling,  instead  of  euca-percha  or  chloro-percha,  stated  that 
he  frequently  kept  up  this  pumping  action  forty  times  to  be  as- 
sured that  the  canals  were  perfectly  filled.  Dr.  Callahan's  rosin 
solution  is  made  by  dissolving  thirty-two  grains  of  the  finest 
rosin  in  one  ounce  of  chloroform  and  pumping  this  into  the  canals 
with  a  hard  gutta-percha  point. 

Dr.  J.  P.  Buckley  has  suggested  that  after  the  euca-percha 
solution  has  been  forced  into  the  canal,  a  gutta-percha  cone  should 
be  dipped  in  chloroform  and  this  pumped  into  the  solution  back 
and  forth  many  times,  the  slight  softening  of  the  cone  by 
chloroform  permitting  it  to  go  further  and  further  into  the  canal 
and  adapt  itself  to  any  inequalities  till  the  root  is  perfectly  filled. 
Radiographs  taken  of  these  cases  would  seem  to  demonstrate  the 
value  of  this  method.  To  facilitate  handling  the  cone  with  the 
pliers  the  large  end  may  be  flattened  by  pressure. 

In  some  instances  where  the  euca-percha  solution  does  not 
seem  thin  enough  to  readily  flow  into  the  canals  a  drop  of  chloro- 
form may  be  placed  in  the  pulp  chamber  with  the  solution, 
thus  making  it  softer  and  more  easily  pumped  into  the  fine  canals. 

If  the  canal  is  so  large  that  the  ordinary  cones  supplied  by  the 
manufacturers  are  not  large  enough  to  fill  it,  a  second  one  may  be 
forced  in  beside  the  first,  or  a  cone  may  be  made  by  the  operator 
for  the  case  in  hand.  Considerable  pressure  should  be  exerted 
on  the  cone  to  make  it  fit  up  tight  to  the  canal  at  the  apex. 
Ordinarily  the  large  end  of  the  cone  will  be  found  standing  up 
in  the  chamber  after  it  has  been  forced  as  far  as  possible  into  the 


252  PRINCIPLES    AND    PRACTICE    OP    FILLING    TEETH 

canal,  and  if  a  heated  instrument  is  applied  to  this  in  the  attempt 
to  compress  it  toward  the  canal,  the  tendency  is  for  the  cone  to 
adhere  to  the  instrmnent  and  be  withdrawn  from  the  canal. 
Instead  of  heating  the  instrument,  the  end  of  the  cone  should  be 
heated  by  directing  a  blast  of  hot  air  upon  it,  and  then  a  broad- 
ended  instrument  may  be  used  to  compress  it  to  place.  In  some 
instances,  particularly  in  three-rooted  teeth  where  the  chamber 
is  large,  it  may  be  well,  before  attempting  to  compress  the 
large  ends  of  the  cones,  to  warm  a  pellet  of  gutta-percha  and 
force  this  to  place  against  the  floor  of  the  chamber  or  subpulpal 
wall,  and  then  gather  the  ends  of  the  cones  over  into  the  pellet  and 
incorporate  the  whole  in  one  mass.  In  doing  this  the  end  of  the 
plugger  may  advantageously  be  wiped  off  with  a  cloth  saturated 
with  one  of  the  essential  oils,  which  will  to  a  large  degree  prevent 
the  adhesion  of  the  gutta-percha  to  the  instrument. 

The  case  now  presents  with  the  cones  in  place  and  the  floor  of 
the  chamber  covered  with  gutta-percha,  but  the  canals  must  not 
be  considered  perfectly  filled.  There  is  yet  too  much  of  the  solu- 
tion remaining,  and  this  must  be  as  largely  displaced  as  possible 
by  the  solid  gutta-percha.  To  do  this  a  root-canal  plugger  should 
be  warmed  and  wiped  with  the  oiled  cloth,  and  gently  forced  into 
the  canals  in  such  a  way  as  to  drive  the  gutta-percha  more  snugly 
into  them.  As  the  gutta-percha  is  compressed  into  the  canals  the 
solution  will  ooze  out  around  the  margins,  and  may  from  time  to 
time  be  absorbed  with  a  pellet  of  cotton.  This  forcing  process 
should  be  continued  till  there  is  assurance  that  the  canals  are 
solidly  filled  with  gutta-percha  and  all  the  surplus  solution  re- 
moved. Over  the  gutta-percha  thus  inserted  a  layer  of  cement, 
preferably  the  oxychlorid  of  zinc,  should  be  used  upon  which  to 
build  the  permanent  filling.  Gutta-percha  does  not  present  a 
sufficiently  firm  or  stable  base  to  justify  an  operator  in  building 
a  metal  filling  upon  it. 

There  is  also  another  reason  for  using  oxychlorid  of  zinc  as  a 
covering  over  the  gutta-percha.  Dr.  A.  E.  Webster,  of  Toronto, 
Canada,  in  a  series  of  experiments  testing  the  sealing  efficiency 
of  various  materials  to  exclude  bacteria  from  the  pulp  canals  of 
teeth  found  that  the  only  method  by  which  this  could  be  done 
with  certainty  with  any  of  the  materials  ordinarily  used  for  the 
purpose  was  by  placing  oxychlorid  of  zinc  in  the  pulp  chamber., 
This  material  would  therefore  seem  an  excellent  root-canal  filling 
in  itself  were  it  not  for  the  fact  that  it  is  difficult  to  force  it  into 


FILLING    PULP-CANALS  253 

small  or  tortuous  canals  and  also  that  in  large  canals  if  it  comes 
in  contact  with  the  tissues  beyond  the  apex  of  the  root  it  is  a  very- 
severe  irritant.  Added  to  this  is  the  extreme  difficulty  of  remov- 
ing it  from  a  canal  in  case  of  trouble.  With  our  present  light 
on  the  behavior  of  pulpless  teeth  under  fillings  the  most  efficient 
means  of  accomplishing  permanent  results  and  making  the  tooth 
entirely  comfortable  for  mastication  is  to  use  Dr.  Cochran's 
material  for  the  finest  canals  and  for  moisten- 
ing the  larger  ones,  then  follow  with  gutta- 
percha cones  in  the  canals  proper  and  cover 
this  by  filling  the  chamber  with  oxychlorid 
of  zinc.  (Fig.  122  a,  gutta-percha  canal 
filling;  h,  oxychlorid  zinc  in  enlarged  por- 
tion of  canal  and  chamber;  c,  metal  filling  in 
cavity.) 

In  case  there  is  no  pericemental  soreness 
the  operation  may  be  completed  with  a 
permanent  filling  at  the  same  sitting,  but  if 
there  is  irritation  present  the  cavity  should 
be  temporarily  sealed  and  the  case  dismissed  for  a  few  days 
till  the  soreness  subsides.  * 

The  question  of  the  proper  filling  of  pulp  canals  is  one  which  in 
recent  years  has  assumed  the  greatest  importance.  The  reve- 
lations of  the  X-ray  have  shown  how  very  few  perfect  root  canal 
fillings  have  been  made,  and  the  wonder  is  that  more  trouble  has 
not  occurred  than  there  has.  It  is  not  so  much  a  problem  of 
filling  canals  as  it  is  of  putting  them  in  proper  condition  to  be 
filled— a  subject  to  be  considered  later.  Then  again  there  is  a 
difference  of  opinion  as  to  what  a  properly  filled  canal  is.  Some 
operators,  notably  Dr.  M.  L.  Rhein  of  New  York,  argue  that 
a  canal  is  not  well  filled  unless  the  filling-material  passes  through 
the  apical  foramen  and  encapsulates  the  end  of  the  root,  while 
others  are  content  if  they  can  get  the  filling  to  the  apex  without 
going  through.  Dr.  Rhein's  contention  is  that  there  is  no 
assurance  of  preventing  infectious  matter  from  entering  the  canal 
unless  the  root  end  is  covered.  It  remains  to  be  seen  what  the 
ultimate  outcome  of  this  kind  of  practice  is.  In  some  respects 
the  argument  is  plausible,  but  in  others  it  does  not  seem  tenable. 
There  can  be  no  question  that  it  is  uncalled  for  in  those  cases  of 
recent  pulp  devitalization  where  the  tissues  in  the  apical  space 
are  supposed  to  be  intact.     To  force  any  material  beyond  the 


254 


PRINCIPLES    AND    PRACTICE    OF   FILLING    TEETH 


end  of  the  root  in  these  cases  is  to  invite  a  soreness  and  subse- 
quent lameness  which  renders  the  tooth  sensitive  to  the  stress  of 
mastication,  and  sometimes  results  in  permanent  discomfort. 
It  is  true  that  in  most  cases  the  soreness  set  up  by  this  procedure 
subsides  after  a  time  provided  the  work  has  been  done  under 
aseptic  precautions  such  as  Dr.  Rhein  takes ;  but  there  are  a  suf- 
ficient number  which  do  not,  to  prove  that  in  some  mouths 
nature  rebels  against  this  kind  of  interference.  In  certain 
cases  where  there  has  been  continued  inflammation  in  the  apical 
space  and  some  denudation  of  the  root  end  by  loss  of  the  peri- 
cemental membrane  it  might  seem  logical  to  flow  over  the  root 
some  chloro-percha  provided  one  could  be  certain  that  it  would 
adapt  itself  accurately  to  the  surface,  but  to  make  this  an  indis- 
criminate practice  in  all  cases  is  considered  too  radical  to  be  advo- 
cated.    There  is  one  region  where  it  should  never  under  any 


Fig.   123. 


circumstances  be  attempted  without  a  previous  X-ray  verifi- 
cation that  it  is  safe  to  do  it.  This  is  in  the  lower  bicuspid 
region  where  the  main  nerve  trunk  runs  along  the  jaw  and  opens 
out  at  the  mental  foramen  so  close  to  the  apices  of  these  teeth 
that  any  substance  forced  beyond  the  root  is  quite  likely  to  cause 
pressure  on  the  nerve  and  lead  to  severe  discomfort. 

With  much  time  to  elapse  yet  before  this  practice  may  be  said 
to  be  on  an  established  basis,  it  would  appear  to  be  the  part  of 
wisdom  to  content  ones  self  with  filling  canals  to  the  extreme 
end  without  going  farther.  And  be  it  said  that  in  many  cases  it 
will  be  found  sufficiently  difficult  to  do  this  without  attempting  to 
fill  the  apical  space. 


FILLING    PULP-CANALS 


255 


Figs.  123,  124,  and  125  may  be  said  to  be  good  examples  of 
root-filling,  where  the  material  reaches  the  end  of  the  canal 
without  passing  through. 


Fig.   124. 


Fig.   125. 


It  goes  without  saying  that  all  canal  operations  should  be 
performed  with  the  greatest  aseptic  precautions — not  that  true 
surgical  asepsis  is  always  possible  iri  the  mouth,  but  that  the 
nearer  we  come  to  this  the  safer  is  our  operation. 


CHAPTER  XX 

THE  X-RAY  IN  THE  MANAGEMENT  OF 
PULPLESS  TEETH 

The  great  value  of  the  X-ray  as  an  aid  to  diagnosis  has  given 
a  new  impetus  to  the  scientific  management  of  pulpless  teeth, 
while  at  the  same  time  it  has,  through  faulty  interpretation, 
led  to  the  loss  of  many  useful  teeth  which  should  have  been  saved. 
With  this  as  with  every  innovation  there  is  a  period  of  over- 
enthusiasm  which  carries  the  profession  beyond  legitimate 
limits,  and  which  works  real  harm  before  it  settles  down  to  its 
proper  status.  This  seems  inevitable,  and  the  profession  must 
not  be  censured  if  they  have  made  mistakes  in  this  particular 
instance.  It  is  the  penalty  of  professional  progress  that  when  any 
thing  new  is  introduced  it  must  of  necessity  be  carried  through 
an  experimental  stage  to  establish  its  utility.  This  had  to  be 
done  with  the  X-ray,  and  if  harm  resulted  in  the  process  it  is 
only  in  accordance  with  past  experience  in  other  lines  of  progress. 
That  the  X-ray  has  limitations  should  be  no  argument  against 
its  wide  employment — -the  only  requisite  being  that  its  limi- 
tations be  recognized. 

In  root  canal  filHng  it  is  useful  in  various  ways.  If  we  are  in 
doubt  about  a  filling  reaching  the  apex  the  X-ray  will  show  us.  If 
a  root  is  curved  the  X-ray  will  enlighten  us  on  the  degree  of 
curvature.  In  all  puzzling  cases  it  should  be  resorted  to, 
and  there  are  some  operators  who  use  it  constantly  in  con- 
nection with  their  canal-filling  operations— checking  up  their 
work  at  intervals  during  its  progress.  They  take  an  X-ray 
with  a  "diagnostic  wire"  in  the  canal  after  they  have  cleaned 
it,  so  that  they  may  know  if  they  have  reached  the  apex  or  if  they 
have  gone  beyond.  When  the  root  is  filled  they  take  another  to 
verify  the  canal  filling,  and  at  various  stages  of  the  operation 
they  resort  to  pictures  to  enlighten  them.  It  would  be  ideal  if 
every  operator  could  do  this  in  every  case,  but  if  this  were  done 
there  would  not  be  enough  operators  to  fill  half  the  canals  that 

256 


THE  X-RAY  IN  THE  MANAGEMENT  OF  PVLPLESS  TEETH       257 

call  for  filling,  and  the  expense  would  be  so  great  as  to  prevent 
many  worthy  people  from  having  their  pulpless  teeth  saved. 

When  the  profession  and  the  people  can  be  educated  to  two 
things  the  problem  of  the  pulpless  tooth  will  not  be  so  serious  as 
it  is  to-day.  These  two  things  are,  first,  that  the  teeth  should  be 
cared  for  so  early  in  life  and  in  such  a  manner  that  there  will  be 
fewer  and  fewer  pulpless  teeth  to  treat;  and  second,  that  when 
a  tooth  does  become  pulpless  its  proper  management  involves  so 
much  time  and  energy  that  it  is  necessarily  an  expensive 
operation. 

But  as  has  been  said,  with  the  number  of  pulpless  teeth  con- 
fronting the  profession  to-day  we  must  do  the  best  we  can  with  the 
facilities  at  hand,  and  fortunately  for  the  pubhc  we  are  able  to 
very  effectively  manage  most  of  these  cases  without  the  additional 
expense  involved  in  the  use  of  the  X-ray.  No  operator  should 
attempt  to  save  a  pulpless  tooth  who  is  not  wiUing  to  put  his 
very  heart  and  soul  into  that  httle  thing  called  a  pulp  canah 
If  he  will  project  his  thought  right  up  into  a  canal  and  concen- 
trate his  every  energy  he  can  clean  out  most  canals  that  can  be 
cleaned,  and  fill  those  that  can  be  filled  without  stopping  to 
make  X-ray  pictures.     The  detail  of  this  is  considered  elsewhere. 

The  X-ray  as  a  Diagnostic  Aid  in  Determining  the  Presence  or 
Absence  of  Infection  in  the  Apical  Region. — It  is  in  this  particular 
that  the  X-ray  has  been  at  times  very  valuable  and  at  times  very 
misleading.  When  the  X-ray  first  came  out  the  conclusion  was 
jumped  at  immediately  that  any  rarefied  area  showing  at  the 
end  of  a  root  in  X-ray  pictures  meant  infection,  and  such  teeth 
were  either  opened  up  at  once  and  treated  or  condemned  and 
extracted.  That  such  a  precedure  was  premature  has  been 
amply  demonstrated  by  the  extraction  of  many  healthy  teeth. 
In  fact  whole  mouths  have  been  needlessly  mutilated  and  cripp- 
led for  hfe  through  the  mistaken  zeal  of  operators  going  solely  by 
X-ray  evidence.  No  man  can  tell  with  certainty  by  the  X-ray 
whether  very  many  of  these  areas  around  pulpless  teeth  are  in- 
fected or  whether  there  has  simply  been  a  thinning  of  the  bone 
from  absorption  at  the  time  the  pulp  died,  and  a  subsequent 
filling  in  of  reparative  tissue,  with  not  the  shghtest  trace  of  in- 
fection. These  areas  have  been  shown  around  teeth  where  the 
canals  have  been  filled  as  perfectly  as  "the  hand  of  man"  can 
fill  them,  and  more  than  this  they  have  been  demonstrated  in  the 
apical  region  of  teeth  with  living  pulps.     Any  irritation  in  this 

17 


258  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

region  seems  to  cause  a  rebellion  of  nature  coupled  with  an  ab- 
sorptive process  in  the  bone,  but  it  does  not  necessarily  follow 
that  there  is  ''infection."  Dr.  L.  E.  Custer,  of  Dayton,  Ohio, 
who  was  the  second  practitioner  to  take  up  X-ray  work  in  den- 
tistry (Dr.  C.  Edmund  Kells  being  the  first)  says  in  this  con- 
nection: "These  light  areas  about  root  apices  are  not  all  ab- 
scesses— not  by  a  long  shot.  After  a  period  of  twenty-two  years 
in  X-ray  work  and  study  of  the  behavior  of  teeth  showing  light 
areas  about  the  root  apices  I  am  prepared  to  show  that  ninety 
per  cent.,  and  perhaps  more,  of  all  pulpless  teeth  show  rare- 
faction about  their  root  apices.  Why  is  this  and  what  does  it 
mean?  My  answer  is  that  nature  never  intended  that  a  tooth 
should  be  pulpless,  and  that  no  matter  how  well  a  pulp  canal  may 
be  prepared  and  filled  it  still  is  not  a  normal  pulp  canal.  The 
apical  foramen  and  region  thereabout  is  the  vital  point  in  the 
whole  proposition,  and  unfortunately  the  apex  is  the  most 
difficult  to  seal  in  a  manner  comfortable  and  non-irritating  to 
nature.  The  unfilled  apex,  or  an  apex  sealed  with  a  foreign 
material,  is  an  irritant,  although  it  may  be  slight,  to  the  surround- 
ing tissues.  The  result  is  the  resorption  of  the  bone  in  the  im- 
mediate vicinity,  and  its  replacement  with  new  tissue  which,  when 
completed,  encysts  the  end  of  the  root.  Now  the  encysting 
tissue,  being  devoid  of  lime  salts,  shows  dark  in  the  skiagraph, 
and  unless  one  has  had  considerable  experience  in  the  obser- 
vation of  these  cases,  he  will  make  the  common  mistake  of  pro- 
nouncing such  skiagraph  as  showing  an  abscess." 

It  is  a  very  difficult  matter  to  decide,  with  our  present  knowl- 
edge, just  which  teeth  showing  light  areas  shall  be  retained  and 
which  extracted.  If  we  remove  all  these  teeth,  or  even  an  ap- 
preciable number  of  them,  we  will  do  an  irreparable  injury  to 
OUT  patients — an  injury  which  can  never  be  condoned  on  the 
subsequent  plea  that  we  did  not  know  better.  If  we  are  obser- 
vant of  the  behavior  of  pulpless  teeth  under  all  sorts  of  condi- 
tions from  the  first  day  that  pulpless  teeth  were  filled  till  now 
we  do  know  better.  That  pulpless  teeth  are  sometimes  a  menace 
to  the  health  of  the  individual  no  thinking  man  will  deny,  but 
if  they  were  the  grave  danger  that  in  some  quarters  they  are  ac- 
counted to  be  to-day  more  than  half  the  people  who  are  now  go- 
ing around  comfortably  with  pulpless  teeth  in  their  mouths  would 
have  been  dead  long  ago. 

On  the  other  hand  we  have  no  right  to  leave  in  the  human 


THE  X-RAY  IN  THE  MANAGEMENT  OF   PULPLESS  TEETH        259 

mouth  any  teeth  which  can  be  demonstrated  to  be  infected. 
Either  the  infection  must  be  removed  by  treatment,  or  the  tooth 
must  come  out.  To  determine  infection,  as  has  been  said, 
is  sometimes  a  difficult  matter,  and  yet  the  X-ray,  taken  with 
close  clinical  observation  of  the  case,  will  aid  us  in  clearing  up 
most  of  the  dangerous  cases.  If  the  individual  shows  evidence 
of  metastatic  infection,  as  indicated  by  pain  and  an  abnormal 
blood-count,  and  in  connection  with  this  if  the  X-ray  demon- 
strates an  appreciable  or  well-defined  area  of  absorption  at  the 
root  end,  where  the  case  has  gone  past  a  mere  thinning  of  the 
bone,  then  there  is  no  question  that  the  tooth  should  be  removed. 
But  this  matter  should  be  determined  not  by  the  physician  alone, 
as  is  so  frequently  the  case,  nor  by  the  dentist  alone,  but  by  a 
careful  conference  between  the  two— to  the  end  that  the  patient's 
best  interests  are  conserved. 

Too  frequently  teeth  have  been  taken  out  under  the  following 
routine:  The  patient  has  been  ill  with  some  affection,  and  has 
consulted  a  physician.  The  significance  of  the  teeth  as  causative 
factors  in  disease  having  been  greatly  magnified  in  the  minds  of 
many  medical  men  in  recent  years  these  organs  are  at  once 
suspected,  and  the  patient  sent  to  an  X-ray  man  for  a  skiagraph. 
Just  here  is  where  an  irreparable  harm  and  a  cruel  injustice  has 
too  often  been  done  to  the  patient.  The  X-ray  man  from  the 
very  nature  of  his  calling  is  prone  to  "look  for  something." 
Frequently  he  is  a  medical  man  who  has  not  studied  the  teeth 
in  any  particular  before  he  began  to  take  pictures  of  them. 
Frequently  he  is  a  dentist  who  has  not  studied  pathological  or 
physiological  processes  as  he  should  have  done.  Frequently 
he  is  neither  a  physician  nor  a  dentist,  and  knows  nothing  what- 
ever about  the  teeth,  or  pathology  or  physiology.  These  men 
may  all  be  conscientious  and  all  may  be  looking  for  the  light, 
but  some  of  them  have  made  most  horrible  blunders  and  com- 
mitted the  most  cruel  wrongs  in  the  name  of  their  calhng.  It 
*is  a  strange  mouth  in  which  they  can  not  find  "infection,"  or 
"abscess"  or  "pyorrhea."  Any  little  lightened  area  around  a 
tooth  is  seized  upon  by  them  as  a  sure  sign  of  disease.  And  the 
chief  wrong  is  done  in  this  way:  Not  content  with  telling  the 
physician  what  they  think  they  have  found  they  write  their 
"diagnosis"  on  a  shp  of  paper  and  hand  it  to  the  patient.  The 
patient  sees  the  alarming  words  "abscess,"  "infection,"  etc., 
and  goes  away  with  the  conviction  that  the  case  is  desperate. 


260  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

People  have  died  of  infection,  so  the  patient  has  heard,  and  an 
abscess  is  always  formidable.  When  the  physician  gets  the 
radiographer's  report  he  naturally  thinks  he  has  found  a  solution 
of  his  patient's  ailment  and  immediately  sends  the  patient  to  an 
exodontist  to  have  the  teeth  removed,  and  the  patient  goes 
gladly  to  be  relieved  of  the  terrors  of  infection. 

While  this  routine  is  in  many  respects  a  perfectly  natural  one, 
yet  it  has  some  serious  flaws.  It  fails  to  take  into  consideration 
the  possible  light  that  the  patient's  dentist  might  throw  on  the 
case.  No  physician  will  claim  that  he  knows  more  about  the 
teeth  than  does  the  dentist,  in  fact  he  usually  claims  that  he 
knows  nothing  at  all  about  them,  and  is  merely  taking  the 
radiographer's  findings  as  a  basis  for  ordering  them  extracted. 
The  physician  does  not  willfully  ignore  the  dentist,  nor  does  the 
X-ray  man  realize  the  serious  harm  he  has  done.  Neither  of 
them  knows  fully  the  importance  of  saving  natural  teeth,  but 
both  of  them  must  in  the  future  be  roused  to  the  grave  harm  they 
may  be  doing  the  patient  by  such  a  procedure  as  the  one  out- 
lined. The  radiographer  must  positively  cease  giving  a  written 
diagnosis  to  the  patient.  Too  much  harm  has  already  been 
done  by  this  means  to  tolerate  it  in  the  future.  His  function 
ceases  when  he  has  reported  to  the  professional  man  who  refers 
the  patient  to  him  what  he  thinks  he  has  found.  Even  then  he 
will  make  mistakes  enough  in  the  faulty  interpretation  which 
seems  an  inevitable  concomitant  of  X-ray  work.  And  the  phy- 
sician must  consult  with  the  dentist  before  ordering  teeth  ex- 
tracted. The  dentist  will  co-operate  with  him  willingly  in  clear- 
ing up  conditions  of  the  mouth,  and  relieving  the  patient  of  any 
disability  connected  with  the  teeth. 

In  short  it  will  require  the  united  efforts  of  the  physician,  the 
dentist,  and  the  radiographer  to  safeguard  the  patient  against 
the  danger  of  metastatic  infection  caused  by  pulpless  teeth  on 
the  one  hand,  and  on  the  other  the  needless,  foolish  and  criminal 
mutilation  of  mouths  by  the  extraction  of  teeth  which  are  in 
no  way  at  fault,  and  which  are  sadly  needed  in  the  physical 
economy  of  the  individual. 


CHAPTER  XXI 
THE  TREATMENT  OF  PUTRESCENT  PULP  CANALS 

When  a  pulp  dies  in  a  tooth  without  the  aid  of  the  operator,  the 
management  of  the  case  is  different  from  that  of  a  recently  de- 
stroyed pulp  where  the  tooth  has  been  under  the  operator's  super- 
vision from  the  destruction  of  the  pulp  to  the  final  fihing  of  the 
root.  The  question  of  infection  enters  materially  into  the  case 
as  soon  as  the  natural  processes  of  dissolution  are  allowed  to  run 
their  course  without  interference. 

Cases  of  this  character  may  be  divided  into  three  classes— 
those  where  the  pulps  die  as  the  result  of  the  approach  of  caries, 
and  which  come  to  the  operator  with  the  cavity  and  canals 
exposed  to  the  fluids  of  the  mouth;  those  where  the  pulps  die 
under  a  filling,  and  those  in  perfectly  sound  teeth  where  the  pulp 
has  been  lost  as  the  result  of  some  injury. 

Each  of  these  classes  may  present  in  one  of  the  following  condi- 
tions :  There  may  be  no  apparent  disturbance  beyond  the  apex  of 
the  root,  with  no  soreness  or  inflammation  of  the  pericemental 
membrane  and  no  pus,  or  there  may  be  decided  soreness  with  an 
elongation  of  the  tooth  from  a  swelling  of  the  membrane,  or  there 
may  be  a  pus  pocket  beyond  the  apex  but  no  external  opening, 
.  and  lastly,  there  may  be  an  abscess  with  a  sinus  passing  through 
the  alveolar  process  and  opening  on  the  gum. 

Treatment  of  Pulpless  Teeth  where  the  Canals  have 

been  Long  Exposed  to  the  Fluids  of  .the  Mouth, 

but  where  there  is  No  Sinous  Opening 

These  cases  must  always  be  treated  with  the  possibility  in 
mind  that  there  may  be  a  blind  and  passive  abscess  in  the  apical 
space  which  is  quite  likely  to  develop  into  a  fiery  furnace  by  a 
little  mismanagement.  The  actual  decay  in  the  cavity  should 
first  be  thoroughly  removed  and  the  pulp-chamber  well  opened 
up.  This  must  be  done  without  the  slightest  manipulation  of  the 
contents  of  the  canals,  or  the  least  pressure  that  is  calculated 
to  force  anything  through  the  apical  foramen.     This  preliminary 

261 


262  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

cleansing  of  the  cavity  may  be  done  without  the  appHcation  of  the 
rubber  dam,  and  the  debris  may  be  rinsed  out  from  time  to  time 
with  a  syringe.  Make  the  cavity  and  chamber  as  mechanically 
clean  as  possible.  Then  apply  the  rubber  dam  and  absorb  the 
moisture  from  the  cavity  with  cotton.  Flood  the  cavity  and 
chamber  with  alcohol,  which  has  a  great  affinity  for  moisture, 
and  absorb  the  alcohol  with  cotton.  This  will  often  extract 
some  of  the  discolored  and  putrescent  contents  of  the  canals. 
Wash  out  well  with  alcohol  in  this  manner  till  the  alcohol  fails 
to  be  discolored  by  contact  with  the  cavity  and  chamber.  Then 
dry  the  chamber  and  as  much  of  the  canals  as  possible  with  warm 
air,  but  do  not  carry  the  desiccation  so  far  as  to  weaken  the  tooth- 
structure.  The  most  effective  medicament  for  these  putrescent 
cases  is  a  formula  suggested  by  Dr.  J.  P.  Buckley,  of  Chicago — 
equal  parts  of  formalin  and  tricresol.  The  prescription  for  this 
is  written  as  follows : 

R     Formalini  \        „„. 
Tricresol   /  ""  ^^^^ 
M.      Sig. — Use  as  indicated. 

Wherever  there  is  putrescence  in  a  tooth  this  remedy  is  the 
best  that  has  yet  been  presented  to  the  profession,  though  it  is 
contraindicated  in  cases  where  the  pulp  has  recently  been  re- 
moved with  no  infection.  The  canals  must  not  at  this  sitting  be 
entered  by  a  broach,  and  no  attempt  made  to  clean  them  by 
instrumentation  except  in  a  slight  degree  in  those  cases  where  the 
canal  is  very  large  and  filled  with  debris  and  putrescent  matter, 
A  canal  like  this  when  flooded  with  alcohol  may  sometimes  be 
approached  very  gently  with  a  smooth  broach,  and  the  debris 
carefully  coaxed  out  and  floated  away  from  the  larger  portion  of 
the  canal  without  disturbing  the  contents  near  the  apex.  The 
reason  that  great  care  is  necessary  in  the  preliminary  treat- 
ment of  these  cases  is  because  if  the  slightest  bit  of  this  pu- 
trescent matter  be  forced  through  the  apical  foramen  it  is  almost 
certain  to  set  up  a  serious  inflammatory  process  which  may  run 
to  abscess.  After  the  chamber  and  canals  have  been  flooded  with 
the  medicament,  some  cotton  saturated  with  it  may  be  loosely 
placed  in  the  chamber  and  the  cavity  sealed  carefully  with  gutta- 
percha or  cement. 

If  it  has  been  possible  to  secure  a  reasonably  perfect  cleansing 
of  the  tooth  and  there  seems  to  be  little  putrescence  left  in  the 


THE  TREATMENT  OF  PUTRESCENT  PULP  CANALS     263 

canals,  the  case  may  be  dismissed  for  one  week,  with  instruction 
to  report  at  once  in  case  of  trouble.  It  should  be  the  aim  of  the 
operator  from  this  time  forward  to  allow  nothing  in  the  tooth  ex- 
cept what  he  places  there,  and  if  trouble  ensues  it  is  better  for  the 
patient  to  seek  the  operator  and  let  him  change  the  dressing 
rather  than  to  pick  it  out  and  again  admit  the  fluids  of  the  mouth. 

In  case  the  dentin  seems  badly  infiltrated  with  putrescence  and 
the  first  treatment  has  apparently  failed  to  control  it  to  the 
operator's  satisfaction,  he  would  better  not  let  the  case  go  a  week. 
Under  these  conditions  the  tooth  should  be  seen  in  twenty-four  or 
forty-eight  hours  and  the  treatment  repeated.  After  this  second 
dressing  the  case  may  be  dismissed  for  a  week.  If  the  tooth  re- 
mains sealed  up  for  this  time  without  discomfort,  the  operator 
may  safely  proceed  to  clean  out  the  canals.  They  should  first  be 
flooded  with  alcohol  and  manipulated  gently  with  a  smooth 
broach  to  float  any  particles  of  debris  that  may  have  been  packed 
into  them.  Even  at  this  second  sitting  the  operator  should  guard 
against  undue  irritation  of  the  apical  tissues  by  the  broach.  He 
should  aim  to  make  his  cleansing  as  thorough  as  possible  without 
forcing  anything  through  the  apex. 

This  mechanical  cleansing  of  the  canals  is  a  very  important 
part  of  the  successful  treatment  of  pulpless  teeth.  When  it  is 
remembered  that  the  cases  at  present  under  consideration  are 
those  in  which  the  contents  of  the  canals  have  long  been  subjected 
to  the  influences  of  infection  and  the  dentin  itself  is  more  or  less 
infiltrated  with  poisonous  material,  it  must  be  apparent  that  the 
most  thorough  cleansing  with  instruments  should  supplement 
any  or  all  kinds  of  medication.  Many  operators  rely  too  largely 
upon  the  efficacy  of  drugs  as  a  short  cut  to  excuse  them  from  the 
necessity  of  painstaking  care  in  removing  mechanically  every 
particle  of  the  putrid  contents  of  canals.  Medication  is  neces- 
sary, but  it  can  never  be  fully  effective  without  the  aid  of 
instrumentation . 

To  be  successful  in  the  mechanical  cleansing  of  canals  it  is  im- 
portant to  first  gain  the  best  possible  access.  The  orifices  of 
canals  leading  from  the  pulp-chamber  are  often  constricted  and 
unapproachable — so  much  so  in  some  instances  as  to  make  it 
difficult  to  find  the  openings.  If  the  chamber  is  well  uncovered 
these  openings  may  readily  be  found  by  following  a  simple  pro- 
cedure. Flood  the  chamber  with  alcohol  and  evaporate  it  with 
warm  air,  when  the  openings  will  ordinarily  be  plainly  visible 


264 


PRINCIPLES   AND    PRACTICE    OF   PILLING    TEETH 


as  soon  as  the  floor  of  the  chamber  is  dry.  These  orifices  should 
at  once  be  widely  reamed  out  with  a  large  Beutelrock  drill  (Fig. 
126) — a  drill  too  large  to  be  admitted  into  the  canal  proper — 
so  as  to  form  a  funnel  leading  to  the  canal  (Fig.  127).  This 
reaming  out  will  perfectly  expose  the  approach 
to  the  canal  and  permit  the  operator  to  ascer- 
tain the  nature  of  the  canal  and  its  general 
ill  I  direction.  This  should  be  carefully  deter- 
1  1  1  JL  mined  with  a  smooth  broach,  one  of  the  very 
best  for  this  purpose  being  the  Rhein  Uni- 
versal "Antalum  Pic,"  and  in  cases  of  con- 
stricted canals  the  proper  cleansing  and  med- 
ication of  the  canal  involves  its  enlargement 

I    1  ti  II       ^^^  *'^®  operator. 

11  I     I  I     '         This  question  of  the  enlargement  of  canals 
I  is  one  of  the  most  intricate  connected  with 

||   .     j     the  treatment  of  pulpless  teeth.     The  attempt 
I  to  enlarge  canals  with  drills  in  the  hands  of 

1    II  U        careless   or  incompetent   operators  has  been 
prolific  of  disaster.     It  is  manifestly  impossi- 
FiG.  126.  ble  to  follow  a  curved  canal  with  a  drill,  and 

the  inevitable  result  has  been  that  operators 
have  drilled  through  the  side  of  the  root.  The  frequency  of 
this  accident  has  led  many  conservative  men  to  make  the  state- 
ment that  a  drill  should  never  be  used  for  enlarging  canals,  and 
yet  in  the  hands  of  a  careful  operator  this  instrument  is  very 
useful  in  the  management  of  these  cases.  It  is  seldom  that 
such  canals  as  those  in  the  buccal  roots  of  the  upper 
molars,  the  mesial  root  of  the  lower  molars,  or  the 
bifurcated  root  of  an  upper  first  bicuspid  can  be 
properly  cleaned  without  a  slight  enlargement. 
Then  again  there  are  many  of  the  larger  canals  in 
which  there  is  an  unevenness  along  the  walls  or  a 
flattening  of  the  canal  which  requires  a  reaming  out 
to  be  properly  treated  and  filled.  In  very  many 
instances  this  may  be  safely  and  quickly  accom- 
plished with  a  drill — at  least  in  the  first  third  or  half  of  the 
canal^ — -provided  the  operator  can  secure  the  proper  approach  to 
it,  and  will  first  study  the  direction  of  the  canal  with  a  broach. 
Unless  he  can  so  hold  the  drill  that  the  approach  is  at  the  proper 
angle,  he  would  better  not  attempt  to  drill  at  all.     Any  undue 


Fig.  127. 


THE  TREATMENT  OF  PUTRESCENT  PULP  CANALS     265 

bending  of  the  drill  while  it  is  revolving  in  a  canal,  or  any  bind- 
ing or  clogging,  is  quite  likely  to  result  in  the  drill  being  broken 
and  lodged  in  the  canal.  The  greatest  care  should  be  taken  to 
avoid  this,  and  consequently  it  is  never  permissible  to  exert 
much  force  on  the  drill  nor  to  attempt  to  drill  around  a  corner. 
In  many  instances  in  the  molars  and  bicuspids  the  drill  should 
be  used  in  the  right-angle  hand-piece  to  admit  of  the  proper 
approach.  It  should  be  passed  back  and  forth  in  the  canal 
with  the  slightest  pressure,  so  that  the  cutting  is  done  without 
clogging,  and  most  of  the  lateral  reaming  should  be  done  on 
the  withdrawal  movement  of  the  drill  instead  of  on  the  forward 
movement. 

If  the  drill  is  thus  used  with  care  and  never  forced  too  near  the 
apex  it  is  capable  of  great  usefulness  in  the  preparation  of  roots 
for  filling,  but  there  are  some  cases  where  the  canals  are  so  curved 
and  the  approach  so  difficult  that  it  is  injudicious  to  attempt  to 
place  a  drill  in  them  at  all.  In  such  cases  the  canals  may  be  en- 
larged by  the  method  suggested  by  the  late  Dr.  J.  R.  Callahan, 
whereby  a  solution  of  sulphuric  acid  is  used  to  soften  the  walls  of 
the  canals  so  that  they  may  be  readily  scraped  out  and  enlarged 
with  a  cleanser.  The  manner  of  using  the  sulphuric  acid  is  as 
follows :  A  forty  per  cent,  solution  of  commercial  sulphuric  acid 
should  be  prepared  and  kept  in  a  glass-stoppered  bottle.  A  drop 
or  two  of  this  may  be  carried  to  the  canals  by  winding  some  fibers 
of  cotton  on  a  wooden  point,  and  dipping  this  in  the  solution  and 
pressing  the  soaked  cotton  against  the  side  of  the  chamber  till 
the  solution  flows  down  into  the  canals.  This  should  then  be 
pumped  to  place  with  a  piano-wire  broach — using  a  new  broach 
each  time.  When  the  smooth  broach  will  readily  pass  back  and 
forth  in  the  canal,  a  Best  cleanser  may  be  used  to  further  pare 
away  the  sides  of  the  canal  and  enlarge  it.  As  soon  as  this 
is  accomplished  to  the  satisfaction  of  the  operator  the  chamber 
and  canals  should  be  freely  flooded  with  a  saturated  solution  of 
sodium  bicarbonate  to  neutralize  the  further  effect  of  the  acid, 
and  this  should  be  continued  till  all  effervescence  ceases.  The 
canals  should  then  be  dried  out  by  flooding  them  with  alcohol  and 
evaporating  it  with  warm  air.  Instead  of  sulphuric  acid,  Dr.  J. 
P.  Buckley  suggests  phenolsulphonic  acid  as  a  better  medium 
for  enlarging  canals,  on  the  ground  that  it  is  fully  as  effect- 
ive and  less  injurious  to  the  tissues. 

If  the  case  has  progressed  favorably  up  to  this  point  and  there 


266  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

are  no  untoward  symptoms,  the  canals  may  be  filled  at  this 
sitting. 

In  those  cases  where  the  canals  have  long  been  exposed  to  the 
fluids  of  the  mouth  there  is  always  the  possibility  of  an  abscess 
occurring  in  the  apical  space  and  discharging  through  the  tooth, 
thus  giving  no  external  evidence  of  its  existence.  In  such  cases 
the  operator  will  ordinarily  be  able  to  detect  the  presence  of  pus 
either  in  his  preliminary  work  on  the  canals,  or  at  least  on  the  cot- 
ton after  it  has  been  sealed  in  the  tooth.  As  soon  as  pus  is 
demonstrated  the  management  of  the  case  is  slightly  changed. 
The  canals  should  at  once  be  thoroughly  cleansed,  and  all  the 
pus  removed  that  is  possible  by  coaxing  it  from  the  apex  toward 
the  chamber  with  a  broach,  and  then  absorbed  with  cotton  or 
with  bibulous  paper  cones  prepared  for  this  purpose.  When  no 
more  pus  can  be  extracted  the  canals  should  be  flooded  with  the 
formalin  and  tricresol  solution  and  some  cotton  placed  in  the 
chamber,  and  the  cavity  sealed.  If  there  has  been  much  pus, 
and  particularly  if  it  has  been  of  an  offensive  character,  the  case 
should  be  seen  in  twenty-four  hours  and  the  treatment  repeated. 
At  the  second  sitting  the  condition  of  the  case  will  indicate  the  line 
of  treatment.  If  there  has  been  perceptible  improvement  there 
need  be  very  little  manipulation  with  the  broach,  but  merely  a 
change  of  dressing.  If  the  pus  seems  as  bad  as  ever  the  broach 
should  be  freely  used,  and  in  some  instances  it  will  be  found 
beneficial  to  work  with  the  broach  till  all  pus  is  removed  and  a 
tinge  of  blood  follows  it  into  the  canal.  As  soon  as  the  blood 
shows  it  is  well  to  pack  the  canal  with  cotton  saturated  with  the 
antiseptic,  and  seal  the  cavity.  Under  these  conditions  the  case 
may  be  dismissed  for  a  week,  with  instructions  to  report  in  the 
event  of  trouble.  If  at  the  end  of  this  period  there  is  still  pus 
it  should  be  drained  with  the  broach  and  the  medicament  sealed 
in  and  allowed  to  remain  two  weeks  if  there  is  no  discomfort. 
After  the  first  thorough  disinfection  of  the  canal  the  tooth  should 
not  be  treated  frequently,  unless  the  operator  is  forced  to  do  so 
by  pain.  Many  of  these  cases  are  kept  in  a  state  of  irritation 
by  too  much  operative  interference,  and  it  will  often  be  found  a 
very  effective  practice  to  give  nature  a  chance. 

When  the  character  of  the  discharge  changes  from  a  thick  yel- 
lowish pus  to  a  thin  serous  fluid — which  is  very  frequently  the 
case — the  canal  should  be  packed  tight  to  the  apex  with  cotton 
saturated  in  the  antiseptic  and  the  case  left  long  enough  to 


THE  TREATMENT  OF  PUTRESCENT  PULP  CANALS     267 

give  it  an  opportunity  to  dry  up.  Except  in  stubborn  cases 
this  will  usually  occur  in  two  weeks,  and  when  the  tooth  has 
remained  for  that  length  of  time  free  from  trouble,  while  tightly 
sealed,  it  may  be  considered  safe  to  fill  it,  provided  the  canal  can 
be  perfectly  dried  to  the  apex. 

In  such  cases  as  these  which  prove  particularly  stubborn, 
and  also  in  other  cases  where  there  is  some  sensitiveness  at 
the  apical  region,  whether  due  to  small  fragments  of  the  pulp 
or  to  hypersensitiveness  of  the  tissues  in  the  apical  space,  a 
certain  line  of  treatment  is  suggested  which  has  seemed  to 
control  these  cases  in  a  more  satisfactory  manner  than  any 
other.  The  canals  are  dried  as  perfectly  as  possible  without 
danger  to  the  tooth  tissue,  and  a  small  twist  of  cotton  into  which 
is  incorporated  a  paste  made  by  mixing  formo-cresol  with  the 
oxid  of  zinc  is  packed  into  each  canal.  The  cotton  should  be 
thoroughly  saturated  with  the  mixture  though  care  must  be 
exercised  not  to  get  any  of  it  through  the  foramen  of  the  root. 
The  cotton  thus  saturated  should  be  made  to  fill  the  entire  pulp 
chamber,  and  over  this  a  cement  filling-  should  be  inserted. 
A  tooth  thus  filled  may  be  allowed  to  remain  for  two  or  even  three 
months,  after  which  the  cement  and  cotton  may  be  removed 
under  aseptic  precautions,  the  canals  carefully  cleaned  and  the 
roots  filled  permanently. 

This  treatment  will  clear  up  some  of  those  stubborn  cases  and 
control  all  sensitiveness  more  acceptably  than  any  thus  far  sug- 
gested. Objection  may  be  made  by  some  practitioners  to  sealing 
so  strong  an  irritant  in  a  canal  as  formo-cresol,  but  used  in  this 
way  it  has  never  been  known  to  do  any  injury,  and  has  invariably 
improved  the  case.  There  are  two  drawbacks  to  its  use — one 
the  fact  that  the  patient  will  not  always  return  at  a  specified 
time  to  have  a  permanent  filling  inserted,  and  the  other  that  it 
is  sometimes  quite  difficult  of  removal  from  the  canals. 

Treatment  of  Pulpless  Teeth  having  a  Sinous  Opening  on 
the  Giun 

Whether  the  sinus  proceeds  from  a  tooth  with  a  filling  in  it  or 
with  an  open  cavity,  the  first  treatment  involves  the  thorough 
opening  up  of  the  chamber  and  canals,  and  the  most  painstaking 
cleansing  to  the  very  apex  if  possible.  With  a  sinus  leading 
from  the  abscess  there  is  little  danger  of  setting  up  inflammation 
by  the  use  of  broaches  or  drills  in  the  canals,  and  the  more  thor- 


268  PRINCIPLES   AND    PRACTICE    OF    FILLING    TEETH 

oughly  this  initial  cleansing  is  done  the  more  readily  may  the 
abscess  be  brought  under  control.  After  the  canals  are  cleansed, 
the  one  from  which  the  abscess  comes — the  location  of  which  may 
usually  be  determined  by  passing  a  probe  into  the  sinus  and 
tracing  its  direction^ — should  be  packed  with  cotton  saturated 
with  oil  of  cloves  and  pressure  brought  to  bear  upon  it  so  as  to 
force  the  agent  through  the  sinus  till  it  appears  on  the  gum.  This 
may  ordinarily  be  best  accomplished  by  placing  a  mass  of  un- 
vulcanized  rubber  into  the  cavity  and  exerting  pressure  upon  it 
with  a  broad-ended  instrument  with  a  pumping  motion  toward 
the  orifice  of  the  canal.  This  will  cause  compression  on  the 
contents  of  the  canal  and  force  the  medicament  through  the  sinus. 
As  soon  as  it  appears  on  the  gum  the  rubber  may  be  removed  and 
formo-cresol  placed  in  the  canals  and  the  cavity  sealed  for  one 
week.  Usually  the  sinus  will  be  found  healed  at  the  end  of  this 
time  if  the  first  treatment  has  been  thorough,  but  in  case  the 
sinus  still  persists  the  treatment  may  be  repeated.  The  same 
rule  in  regard  to  waiting  to  give  nature  a  chance  after  the  first  or 
second  treatment  should  be  followed  here  as  with  the  previous 
cases  under  consideration.  Many  a  chronic  case  will  heal  in  two 
.weeks  when  it  will  not  heal  in  one. 

In  case  a  second  or  third  injection  fails  to  close  the  sinus 
it  may  be  taken  for  granted  that  there  is  some  caries  of  the 
process  surrounding  the  apex  of  the  root,  or  such  a  roughening 
of  the  end  of  the  root  as  to  prevent  the  tissues  from  healing  over 
it.  Under  these  conditions  the  root-canal  should  be  filled  and 
the  external  sinus  packed  with  cotton  to  enlarge  it.  The  cotton 
should  be  changed  every  twenty-four  hours  for  a  larger  piece  till 
the  sinus  is  sufficiently  expanded  to  permit  of  perfect  access  to 
the  end  of  the  root.  When  this  is  attained  a  sharp  bur  in  the 
engine  should  be  used  to  ream  out  the  carious  bone  and  smooth 
the  rough  end  of  the  root — if  necessary,  cutting  off  a  piece  of  the 
root.  The  opening  thus  made  should  be  syringed  out  with  an  an- 
tiseptic solution  and  freely  plastered  with  a  paste  made  by  mixing 
boric  acid  with  oil  of  cloves,  after  which  some  antiseptic  gauze 
should  be  packed  into  it  to  keep  it  from  healing  at  the  orifice  be- 
fore granulations  have  perfectly  filled  in  the  interior.  The  dress- 
ing should  be  changed  every  twenty-four  hours,  and  as  the  open- 
ing heals  from  within  the  gauze  may  be  made  less  and  less  till 
it  is  not  required  at  all.  This  will  cure  the  most  stubborn  case — 
and  it  may  be  said,  in  passing,  that  it  is  only  the  very  stubborn 


THE  TREATMENT  OF  PUTRESCENT  PULP  CANALS     269 

cases  that  call  for  it,  the  vast  majority  of  abscesses  usually  healing 
without  recourse  to  such  surgical  interference.  It  should  be  the 
aim  of  the  operator  to  cure  all  cases,  if  possible,  by  treatment 
through  the  pulp-canal  in  the  ordinary  way,  but  where  this  opera- 
tion seems  imperatively  necessary  it  must  not  be  considered  a 
very  serious  or  formidable  one.  A  httle  delicacy  an  the  part  of 
the  practitioner  will  usually  enable  him  to  perform  it  without 
appreciable  pain  to  the  patient. 


Opening  into  Filled  Teeth  in  which  the  Pulps  have  Died,  but 
have  lain  Dormant 

It  will  occasionally  be  found  that  pulps  die  under  fillings  with- 
out giving  any  particular  trouble  to  the  patient,  and  the  tooth  re- 
mains passive  for  an  indefinite  time  with  no  indication  of  abscess. 
In  opening  into  these  teeth  for  the  purpose  of  treating  and  filling 
the  canals  the  very  greatest  care  is  necessary  to  avoid  trouble. 
There  seems  to  be  a  disposition  in  such  cases  for  the  most  active 
inflammation  to  ensue  the  moment  an  opening  is  made  through 
the  filling.  This  is  all  the  more  embarrassing  to  the  operator  in 
view  of  the  fact  that  the  trouble  dates  from  the  time  of  his  inter- 
ference with  the  case,  and  it  is  sometimes  difficult  to  explain  to  the 
patient  that  it  is  not  due  to  his  carelessness.  These  cases  should 
therefore  be  approached  with  the  utmost  caution,  and  everything 
should  be  in  readiness  for  immediate  medication  the  moment  the 
drill  penetrates  through  the  filling.  On  account  of  its  dehy- 
drating properties,  alcohol  would  seem  to  be  the  best  agent  for  the 
first  flooding  of  the  cavity.  This  should  be  conveniently  at  hand, 
and  at  once  admitted  to  the  opening  when  the  drill  passes  into  the 
chamber.  After  letting  it  remain  a  moment,  the  surplus  may  be 
absorbed  with  cotton  followed  by  warm  air  till  the  cavity  is  dry. 
The  opening  through  the  filling  may  be  then  enlarged  as  indi- 
cated, and  the  cavity  again  flooded  with  alcohol.  A  very  gentle 
stirring  of  the  alcohol  in  the  chamber  is  permissible  with  the 
object  of  washing  out  any  debris  or  putrescent  matter  that  may  be 
present,  but  no  attempt  should  be  made  to  use  instruments  in  the 
canals  through  fear  of  forcing  infectious  matter  beyond  the  apex. 
After  the  chamber  is  well  washed  with  alcohol  it  should  be  dried 
again,  and  a  pellet  of  cotton  saturated  with  formalin  and  tricresol 
placed  loosely  in  the  chamber  and  the  opening  sealed  with  gutta- 
percha.    The  subsequent  management  of  the  case  is  the  same  as 


270  PKINCIPLES    AND    PEACTICE    OF    FILLING    TEETH 

that  already  outlined  for  the  treatment  of  pulpless  teeth  having 
no  sinous  openings. 

The  Management  of  Pulpless  Teeth  m  the  Anterior  Part  of  the 
Mouth  to  Prevent  Discoloration 

The  tendency  of  all  pulpless  teeth  to  take  on  discoloration  ren- 
ders it  necessary  for  the  operator  to  exercise  especial  caution  with 
teeth  exposed  to  view,  to  avoid  as  largely  as  may  be  the  resultant 
disfigurement  of  his  patient.  If  a  pulp  must  be  lost  in  an  incisor, 
it  is  preferable,  if  possible,  to  destroy  it  by  means  of  pressure  an- 
esthesia rather  than  to  apply  arsenic,  on  account  of  the  fact  that 
many  cases  are  on  record  where  the  application  of  arsenic  has  re- 
sulted in  a  sudden  clouding  of  the  tooth  from  the  active  inflam- 
mation induced.  If  it  is  deemed  necessary  to  use  arsenic,  only 
a  very  small  quantity  should  be  used,  and  it  should  not  be  allowed 
to  remain  longer  than  twenty-four  hours.  At  the  end  of  this 
time  the  arsenic  should  be  removed,  and  the  cavity  washed  out 
with  alcohol  and  dried,  after  which  some  light-colored  antiseptic 
may  be  sealed  in  the  cavity  for  one  week — using  cement  as  the 
sealing  agent.  It  should  be  a  cardinal  principle  in  the  treatment 
of  these  cases  never  to  allow  the  fluids  of  the  mouth  to  gain  en- 
trance to  the  cavity  after  the  case  comes  under  the  care  of  the 
operator,  and  in  the  sealing  of  medicaments  it  is  safer  to  use 
cement  than  gutta-percha.  The  latter  may  not  be  so  permeable 
to  moisture  under  long-continued  exposure  as  the  former,  but  the 
ready  adaptation  and  adhesion  of  cement  to  cavity-walls  renders 
it  the  most  certain  sealing  agent.  Along  this  same  line  no  treat- 
ment should  ever  be  made  without  the  application  of  the  rubber 
dam. 

As  soon  as  the  pulp  is  removed  and  the  canal  dried  the  root 
should  be  filled,  and,  if  possible,  a  permanent  filling  inserted  in 
the  crown  at  the  same  sitting.  If  these  precautions  are  taken  it 
will  seldom  be  found  that  a  tooth  becomes  sufficiently  discolored 
to  be  noticeable. 

Bleaching  Teeth 

It  is  scarcely  within  the  province  of  the  present  work  to  go 
minutely  into  the  subject  of  treating  discolored  teeth,  but  a  simple 
suggestion  may  be  made  as  to  a  certain  method  of  bleaching  which 
will  be  found  effective  in  a  large  percentage  of  cases  applying  to 
the  operator.     When  a  tooth  presents  which  has  become  dis- 


THE  TREATMENT  OF  PUTRESCENT  PULP  CANALS      271 

colored  as  the  result  of  loss  of  the  pulp,  the  first  consideration  is 
to  put  the  canal  in  a  healthy  condition  and  fill  it.  Then  the  tooth 
may  be  bleached  in  the  following  way:  The  root-filling  should  be 
removed  sufficiently  to  allow  the  bleaching  agent  to  act  on  the 
tooth  well  under  the  line  of  the  free  margin  of  the  gum — many 
of  these  cases  showing  the  most  marked  discoloration  near  the 
gum.  The  cavity  should  then  be  dried  out,  and  a  pellet  of  cotton 
saturated  with  a  fresh  solution  of  the  twenty-five  per  cent,  pyro- 
zone  should  be  sealed  in  the  cavity  with  cement  for  twenty-four 
or  forty-eight  hours,  at  the  end  of  which  time  a  very  perceptible 
bleaching  will  ordinarily  have  occurred.  In  some  stubborn  cases 
it  may  be  necessary  to  repeat  the  treatment — always  being  careful 
to  apply  the  rubber  dam  at  each  sitting,  and  invariably  sealing 
with  cement.  If  this  method  is  carefully  followed  the  results  are 
usually  very  gratifying  and  the  bleaching  quite  permanent. 

Another  effective  way  of  bleaching  where  it  is  desired  to  ac- 
complish the  purpose  at  a  single  sitting  has  been  suggested  by  Br. 
J.  P.  Buckley,  as  follows: 

"  The  dam  is  placed  over  the  tooth  and  adjacent  teeth.  A  thin 
platinum  band  is  wrapped  around  the  tooth  to  be  bleached  and 
white  gutta-percha  warmed  and  used  to  form  a  pocket  about  the 
cavity.  By  the  use  of  a  small  gold  or  platinum  spoon  some  so- 
dium dioxid  is  placed  in  the  cavity  and  forced  some  distance  up 
the  root-canal  with  a  glass  instrument.  Distilled  water  is  now 
dropped  into  the  cavity,  and  a  piece  of  platinum  held  over  the 
cavity  to  force  the  generated  oxygen  into  the  dentin.  After 
sufficient  time  to  allow  the  oxygen  to  work,  the  cavity  should  be 
washed  and  dried  and  the  operation  repeated  if  necessary. 
Should  it  be  found  impossible  to  remove  the  pigment  mechan- 
ically with  water,  a  three  per  cent,  solution  of  sulphuric  acid  may 
be  used  to  chemically  dissolve  it,  after  which  wash  with  water  and 
let  dry,  preferably  without  using  hot  air.  Now  burnish  a  paste 
of  precipitate  calcium  phosphate  and  distilled  water  into  the 
lower  third  of  the  root  and  against  all  exposed  dentin.  Make  a 
base  for  final  filling,  using  light-colored  cement." 


CHAPTER  XXII 

THE  MANAGEMENT  OF  CHILDREN'S  TEETH 

This  subject  presents  itself  in  two  phases  for  our  consideration 
from  an  operative  point  of  view — the  care  of  the  deciduous  teeth, 
and  the  care  of  those  of  the  permanent  set  which  appear  in 
childhood.  The  problems  which  confront  the  operator  in  the 
one  case  are  not  precisely  the  same  as  those  in  the  other,  and 
the  intelligent  practitioner  will  study  the  two  situations  from  a 
somewhat  different  basis.  The  object  in  the  management  of  the 
deciduous  set  is  merely  to  do  palliative  work,  with  the  idea  of 
keeping  the  patient  comfortable  for  a  period  of  a  few  years,  rather 
than  to  undertake  thorough,  permanent,  and  artistic  operations. 
The  avoidance  of  pain  at  this  stage  is  very  important,  and  this  of 
itself  often  involves  the  performance  of  temporary  work.  While 
the  operator  is  not  by  any  means  free  from  this  restriction  in  his 
management  of  the  permanent  teeth,  particularly  those  which  ap- 
pear early,  yet  his  aim  as  he  approaches  these  should  be  in  the  di- 
rection of  attaining  the  greatest  possible  permanence  to  his  opera- 
tions, with  the  idea  ever  in  mind  that  the  highest  exercise  of  his  art 
involves  the  saving  of  these  organs  for  a  lifetime. 

Management  of  the  Deciduous  Teeth 

The  impression  among  many  of  the  laity  that  these  teeth  may 
well  be  neglected,  so  far  as  operative  procedures  are  concerned,  on 
the  basis  that  they  are  eventually  lost  through  natural  processes, 
should  be  corrected  by  the  profession  at  every  opportunity.  Be- 
yond the  patent  fact  of  much  possible  suffering  on  the  part  of  the 
patient  and  much  injury  to  the  health  through  neglected  and  ab- 
scessed teeth,  there  is  a  question  of  habit  which  has  an  important 
bearing  on  the  future  welfare  of  the  patient.  These  little 
folks  are  very  impressionable  at  such  a  tender  age,  and  readily 
acquire  habits  which  may  conduce  to  either  their  permanent  bene- 
fit or  injury.     If  a  deciduous  tooth  decays  and  is  allowed  to  go 

272 


THE    MANAGEMENT    OF    CHILDREN'S    TEETH  273 

without  attention,  it  sooner  or  later  becomes  sensitive  to  the  im- 
pact of  food  in  mastication,  and  the  Httle  patient  often,  without 
being  able  to  explain  the  real  source  of  the  discomfort,  intui- 
tively avoids  chewing  upon  the  side  of  the  mouth  affected.  This 
leads  to  imperfect  mastication,  and  where  there  are  several  sensi- 
tive teeth  in  the  mouth  it  may  lead  to  an  almost  entire  cessation 
of  mastication;  so  that  a  process  of  bolting  the  food  is  inaugu- 
rated which  may,  and  undoubtedly  often  does,  cling  to  the  patient 
as  a  habit  through  life. 

If  a  close  observer  will  carefully  note  the  workings  of  mastica- 
tion in  the  mouths  of  the  individuals  he  meets,  he  may  of  course 
get  a  reputation  for  rudeness,  but  he  will  also  be  impressed  with 
the  variations  in  the  methods  practised  and  the  degree  of  effect- 
iveness exemplified  in  the  different  mouths.  These  variations 
occur  in  individuals  who  have  teeth  of  relatively  equal  efficiency, 
so  that  they  must  be  traced  largely  to  matters  of  habit ;  and  it  is 
natural  to  conclude  that  these  habits  were  formed  in  childhood. 
When  it  is  considered  that  effective  mastication  is  a  weighty 
factor  in  the  health  and  longevity  of  the  individual,  it  may  be 
seen  how  important  it  becomes  that  we  keep  the  teeth  of  children 
in  a  condition  comfortable  under  the  trituration  of  food  and  con- 
ductive to  habits  of  thorough  mastication. 

A  child  should  be  brought  to  the  dentist  at  regular  intervals  for 
examination  from  the  time  of  the  third,  or  at  latest  the  fourth, 
year  of  age.  The  first  operation  usually  necessary  is  fortunately 
that  of  cleaning  the  teeth,  and  this  may  be  accomplished  as  a 
sort  of  a  frolic  on  the  part  of  the  little  patient  and  without  any 
pain.  If  the  teeth  are  cleaned  several  times  before  any  filling 
becomes  necessary  the  dread  of  the  dental  chair  is  largely  over- 
come, and  filling  operations  are  undertaken  with  a  better  prospect 
of  success. 

The  materials  to  be  used  for  filling  the  deciduous  teeth  are  ordi- 
narily limited  to  gutta-percha,  cement,  and  amalgam.  For  the 
anterior  teeth  cement  must  be  considered  the  chief  reliance,  on 
account  of  the  nature  of  the  decay  which  usually  attacks  these 
teeth.  The  cavities  are  for  the  most  part  shallow  and  not  well 
defined  in  outline,  nor  is  it  possible  in  many  instances  to  establish  a 
perfect  outline  or  trim  to  a  well-formed  margin.  After  the  re- 
moval, more  or  less  thoroughly,  of  the  decay,  the  filling  must  be 
plastered  against  the  cavity  and  remain  by  its  own  adhesive  prop- 
erties.    Cement  is  the  only  material  which  can  be  relied  upon 

18 


274  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

to  do  this,  the  fact  that  it  is  necessary  to  renew  it  occasionally 
being  its  chief  limitation.  It  is  ordinarily  not  a  very  diffi- 
cult problem  to  save  the  deciduous  incisors  and  keep  them  com- 
fortable till  the  eruption  of  the  permanent  ones,  on  account  of  the 
early  age  at  which  they  are  shed;  but  the  care  of  the  deciduous  mo- 
lars becomes  a  more  serious  matter.  They  are  usually  retained 
four  or  five  years  longer  than  the  incisors,  and  those  years  are 
sometimes  very  trying  both  to  patient  and  operator.  Occlusal 
cavities  in  these  teeth  are  ordinarily  easily  managed  with  either 
cement  or  amalgam,  the  choice  being  governed  by  the  degree  of 
thoroughness  with  which  the  cavity  may  be  excavated  without 
pain.  If  a  good  preparation  can  be  made,  and  the  pulp  is  not  too 
nearly  involved,  amalgam  should  be  used  on  account  of  its  greater 
permanence,  but  in  some  instances  the  teeth  are  so  sensitive  that 
the  most  that  can  be  accomplished  is  to  break  down  the  thin  over- 
hanging enamel-walls,  remove  the  softer  portions  of  the  carious 
dentin,  and  force  cement  into  the  cavity.  When  cement  is  used 
under  these  conditions  it  should  be  placed  in  position  with  con- 
siderable pressure.  It  should  also  be  used  in  such  excess  that  the 
entire  occlusal  surface  of  the  tooth  is  covered  even  beyond  the 
borders  of  the  cavity,  so  far  as  this  may  be  done  without  inter- 
fering with  the  occlusion.  To  accomplish  this  conveniently,  and 
also  to  protect  the  filling  from  moisture  for  a  few  minutes  with- 
out stuffing  the  mouth  full  of  napkins  or  absorbent  rolls,  the 
index  finger  of  the  operator  may  be  brought  down  upon  the  ce- 
ment as  it  lies  on  the  tooth  and  the  whole  occlusal  surface  sub- 
jeted  to  pressure,  so  that  the  cement  will  be  forcibly  carried  into 
every  groove  or  inequality  on  this  surface  and  the  excess  be 
squeezed  out  over  the  marginal  ridges  of  enamel.  If  the  finger 
be  held  upon  the  cement  a  few  minutes  the  result  is  a  filling 
which  not  only  includes  the  cavity  itself,  but  also  protects  the 
grooves  and  other  vulnerable  points  radiating  from  it. 

The  problem  of  chief  concern  in  the  care  of  these  teeth  relates  to 
the  management  of  occluso-proximal  cavities.  There  are  two 
factors  which  tend  to  make  these  cavities  especially  difficult  to 
control' — the  almost  universal  sensitiveness  which  we  find  present, 
thus  preventing  an  adequate  preparation  of  the  cavity  to  retain 
the  filling,  and  a  gradual  separating  of  the  teeth  from  the  natural 
expansion  of  the  jaw,  so  as  to  lead  to  constant  complaint  on  the 
part  of  the  patient' of  food  wedging  between  the  filling  and  the 
proximating  tooth  and  lodging  in  the  interproximal  space.     This 


THE    MANAGEMENT    OF    CHILDREN'S    TEETH  275 

discomfort  is  often  manifest  as  the  teeth  drift  apart,  even  when 
no  decay  has  occurred,  but  it  is  particularly  annoying  between 
filled  teeth  where  it  has  not  been  possible  to  contour  sufficiently 
to  maintain  perfect  contact  with  the  proximating  tooth.  The 
insecurity  of  anchorage  usually  imposes  upon  the  operator  the 
alternative  of  making  fillings  with  limited  contour,  and  this  soon 
leads  to  a  pocket  between  the  teeth,  which  proves  a  constant 
source  of  discomfort. 

Ordinarily  where  the  proximal  surface  of  a  molar  is  decayed 
the  proximating  surface  of  the  one  next  to  it  also  becomes  in- 
volved, and  this  complicates  matters  so  far  as  making  separate  fill- 
ings is  concerned.  In  desperate  cases,  where  both  teeth  are 
decayed,  it  may  be  advisable  to  bridge  across  the  interproximal 
space  and  join  the  fillings  together.  This  will  at  once  do  away 
with  the  difficulty  of  food  wedging  between  the  teeth,  and  will 
often  prove  a  relief  to  the  patient  where  separate  fillings  have 
been  a  failure.  But  there  are  only  two  materials  which  are 
suitable  for  this  purpose.  If  cement  is  employed  it  is  only  a  mat- 
ter of  a  few  weeks  when  the  whole  mass  is  found  loose  between 
the  teeth;  so  that  the  operator  is  limited  to  gutta-percha  and  amal- 
gam. If  the  former  is  used  it  will  ordinarily  not  draw  away  from 
either  cavity,  and  it  is  excellent  as  a  temporary  expedient,  but 
it  is  so  easily  worn  out  that  it  is  at  best  only  a  makeshift.  Amal- 
gam is  probably  the  most  serviceable  material  for  these  cavities. 
It  is  not  worn  away  by  attrition,  and  will  remain  more  securely 
fixed  than  cement,  though  in  some  instances  the  case  will  present 
in  a  few  months  with  the  filling  loosened  from  one  of  the  cavities 
while  the  other  remains  firm.  The  reason  for  this  lies  in  the 
individual  movement  of  the  teeth,  the  one  with  the  lesser  re- 
tention giving  way. 

A  great  aid  in  securing  firmness  of  these  fillings  when  joined  to- 
gether, no  matter  which  material  is  used,  is  to  first  place  a  metal 
bar  across  the  interproximal  space,  with  one  end  resting  on  the 
gingival  wall  of  one  cavity  and  the  other  on  the  gingival  wall  of 
the  other,  and  building  the  fillings  around  and  over  it.  This  locks 
the  teeth  together  more  securely,  and  affords  perfect  protection 
to  the  gum .  These  bars  may  conveniently  be  made  from  German 
silver  wire  rolled  flat,  and  cut  to  a  suitable  length  for  the  case  in 
hand. 

This  operation  is,  of  course,  contraindicated,  except  in  the 
most  desperate  cases,  on  account  of  its  evident  limitations,  but  as 


276  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

a  temporary  expedient  it  will  often  be  found  of  service  in  render- 
ing the  little  patient  comfortable. 

Treatment  of  Exposed  Pulps  in  Deciduous  Teeth 

When  a  pulp  becomes  exposed  in  a  deciduous  tooth,  it  is  seldom 
advisable  to  make  an  application  for  its  destruction.  If  the 
patient  applies  with  pain  this  can  ordinarily  be  quickly  relieved 
by  syringing  the  cavity  well  with  tepid  water  to  remove  loose 
debris,  and  carefully  clearing  away  with  a  spoon  excavator  any 
hard  material  which  may  be  causing  pressure  on  the  pulp.  This 
is  to  be  followed  by  an  application  of  oil  of  cloves  or  phenol 
on  a  pledget  of  cotton  about  the  size  of  the  head  of  a  pin,  covered 
with  dry  cotton  to  fill  the  cavity.  When  the  pain  is  relieved, 
it  is  better  to  treat  the  tooth  in  a  palliative  way  than  to  subject 
the  pulp  to  the  action  of  drugs  sufficiently  powerful  to  work  its 
destruction.  Arsenic  should  never,  under  any  circumstances, 
be  used  in  a  deciduous  tooth.  The  risk  is  too  great  of  doing 
serious  injury  to  the  surrounding  parts,  and  the  necessities  of  the 
case  seldom  call  for  any  such  radical  treatment. 

An  exposed  pulp  may  be  treated  by  flowing  over  it  a  paste 
made  by  mixing  oil  of  cloves  with  the  oxid  of  zinc  or  the  powder 
which  comes  with  cement  fillings.  This  paste  is  anodyne  and 
antiseptic,  and  a  pulp  will  usually  remain  comfortable  under  it. 
It  should  be  protected  by  a  filling  of  gutta-percha  or  cement. 
If  a  pulp  has  begun  to  suppurate,  this  paste  sealed  in  with  soft 
gutta-percha  is  an  excellent  means  of  keeping  the  tooth  com- 
fortable while  the  pulp  is  dying.  It  may  be  left  in  under  these 
conditions  for  a  week  or  two,  as  the  case  indicates,  and  on  its 
removal  the  canals  can  ordinarily  be  cleaned  and  filled  with  safety. 
It  will  usually  be  found  that  when  a  pulp  has  once  become  ex- 
posed in  a  deciduous  tooth  it  is  only  a  matter  of  time  when  it  will 
die.  These  pulps  do  not  seem  to  be  very  tenacious  of  life,  and 
it  does  not  require  an  application  of  arsenic  to  kill  them.  They 
will  often  die  even  under  this  antiseptic  paste,  but  when  protected 
in  •»  this  way  they  seldom  give  the  slightest  discomfort  while 
dying,  and  the  tooth  will  often  remain  free  from  pain  till  it  is  shed. 
In  other  cases  it  may  become  somewhat  sore  following  the  death 
of  the  pulp,  and  even  end  in  a  small  abscess  opening  on  the  gum; 
but  there  is  never  the  intense  suffering  and  excessive- swelling 
which  sometimes  accompanies  teeth  that  are  neglected  and  left 
open  to  the  fluids  of  the  mouth. 


THE    MANAGEMENT    OF    CHILDREN'S    TEETH  277 

Treatment  of  Abscessed  Deciduous  Teeth 

The  canals  should  be  as  carefully  cleaned  as  possible  by  me- 
chanical means,  and  then  packed  with  cotton  saturated  with  oil  of 
cloves.  Some  unvulcanized  rubber  sufficient  in  size  to  fill  the 
cavity  should  then  be  forced  down  upon  the  cotton,  and  compres- 
sion made  on  the  rubber  till  the  oil  of  cloves  comes  out  at  the 
sinous  opening  on  the  gum.  When  this  is  accomplished,  if  the 
preliminary  cleansing  has  been  thorough  and  the  contents  of  the 
canals  have  not  been  too  offensive,  the  tooth  may  be  filled  at 
the  same  sitting.  If  the  dentin  seems  saturated  with  foul  matter, 
the  canals  should  be  packed  with  cotton  and  oil  of  cloves  and 
sealed  with  gutta-percha  for  a  week.  If  the  sinus  still  remains 
open  at  the  end  of  that  time,  it  should  again  be  injected  with  oil 
of  cloves  and  the  tooth  filled  in  the  following  way:  The  pulp- 
chamber  and  canals  should  be  flooded  with  Dr.  Cochran's 
solution,  and  some  temporary  stopping  slightly  warmed  should 
be  forced  down  into  each  canal  till  the  solution  shows  at  the 
opening  of  the  sinus.  The  temporary  stopping  should  be  left 
in  the  canals  as  a  root-filling,  and  the  cavity  proper  may  then  be 
filled  with  whatever  material  is  indicated. 

Following  this  treatment,  these  cases  will  almost  invariably 
heal  and  give  no  further  trouble.  Indeed,  the  management  of  ab- 
scessed deciduous  teeth  is  usually  a  matter  of  not  much  difficulty, 
provided  the  patient  is  at  all  tractable  and  there  is  enough  of  the 
tooth  left  to  work  upon. 

It  will  be  noted  that  oil  of  cloves  is  advocated  for  treating  these 
cases  instead  of  formalin  and  tricresol.  The  latter  has  a  disagree- 
able odor,  and  it  is  not  always  possible  to  avoid  getting  some  of 
it  in  the  mouth  of  a  child  which  of  course  might  do  injury  on 
account  of  its  strong  irritating  properties.  Anything  with  a  dis- 
agreeable taste  will  prejudice  the  child  against  dental  treatment, 
and  should  as  largely  as  possible  be  avoided. 

The  Management  of  Permanent  Teeth  in  Childhood 

This  is  one  of  the  most  important  problems  in  the  entire  prac- 
tice of  dentistry.  Decay  of  the  teeth  has  been  called  essentially 
a  disease  of  youth,  and  it  is  undoubtedly  true  that  during  child- 
hood it  seems  to  make  its  fiercest  attacks.  The  teeth  to  suffer 
must  from  its  ravages  are  accordingly  among  those  which  erupt 
earliest,  and  of  these  may  be  mentioned  particularly  the  first 
permanent  molars.     These  teeth  should  be  the  object  of  especial 


278  PRINCIPLES    AND    PRACTICE    OF   FILLING    TEETH 

care  on  the  part  of  the  dentist.  Beyond  the  fact  that  they  are 
called  upon  to  do  longer  service  in  the  mouth  than  any  of  the 
other  teeth,  they  have  an  important  function  in  the  dental  arch 
which  is  not  often  carefully  enough  considered  by  practitioners. 
This  relates  to  the  time  of  their  eruption  and  to  the  position  they 
occupy  in  the  arch.  To  them  it  is  given  to  be  the  standard- 
bearers  of  the  jaws  during  that  period  which  intervenes  between 
the  loss  of  the  deciduous  molars  and  the  growth  to  full  length  of 
the  bicuspids  and  second  permanent  molars.  Without  the  first 
permanent  molars  in  their  proper  position  at  this  time  the  jaws 
are  allowed  to  drop  too  close  together,  so  that  the  upper  incisors 
overlap  the  lower  incisors  more  than  is  normal,  and  the  bicuspids 
and  second  molars  are  never  allowed  to  assume  their  true  length 
and  position.  This  matter  of  maintaining  the  jaws  in  their 
proper  relation  one  to  the  other  is  very  important,  as  it  relates 
to  the  symmetry  of  the  face  and  to  the  most  perfect  mastication, 
and  every  effort  should  therefore  be  made  to  preserve  the  first 
permanent  molars  in  their  normal  length.  These  teeth  should 
be  watched  from  the  time  of  their  eruption,  and  on  the  slightest 
approach  of  caries  they  should  be  carefully  filled.  In  case  the 
patient  fails  to  apply  to  the  dentist  till  decay  has  so  involved  the 
teeth  that  they  are  badly  broken  down  and  not  capable  of  main- 
taining the  jaws  in  their  correct  position,  every  effort  should  be 
made  to  so  build  them  up  with  fillings  that  this  function  be  not 
lost,  and,  failing  in  this,  they  should  be  crowned  even  at  this 
early  age  rather  than  yield  them  up  to  the  forceps.  It  is  a  safe 
statement  to  make  that  no  arch  was  ever  found  in  which  articu- 
lation of  the  teeth  was  perfect  where  the  first  permanent  molars 
had  been  lost.  Even  in  those  cases  where  the  second  molars  have 
come  forward  and  are  in  contact  with  the  second  bicuspids, 
and  the  occlusion  appears  to  be  perfect  from  the  buccal  aspect; 
if  models  are  made  of  the  two  jaws  and  examined  from  the  lingual 
surfaces,  it  will  invariably  be  found  that  the  articulation  is  very 
defective. 

The  choice  of  materials  to  be  used  for  filling  these  teeth  in  the 
early  history  of  their  eruption  must  be  governed  largely  by  the 
ability  and  disposition  of  the  patient  to  withstand  dental  opera- 
tions. If  decay  occurs  in  the  occlusal  surface  during  the  period 
of  the  tooth's  eruption  through  the  gum,  as  is  sometimes  the  case, 
the  most  serviceable  material  to  check  the  disease  at  this  time  is 
usually  cement.     It  may  be  employed  with  less  thorough  prepara- 


THE    MANAGEMENT    OF    CHILDREN'S    TEETH  279 

tion  of  the  cavity  than  is  demanded  for  metal  filHngs,  and  it  will 
prove  effective  as  a  temporary  expedient  to  tide  the  tooth  over 
this  critical  period  till  it  is  fully  erupted  and  in  a  condition  to 
receive  a  more  permanent  operation. 

This  material  may  be  used  in  the  very  earliest  stages  of  decay, 
even  when  the  flap  of  gum  has  not  entirely  receded  from  the  oc- 
clusal surface;  and  in  some  mouths  where  the  tendency  to  decay 
seems  to  be  very  great  it  is  well  to  use  it  as  a  preventive  by  forcing 
it  into  the  grooves  and  sulci  of  the  occlusal  surface  before  actual 
decay  has  begun. 

This  will  often  so  protect  the  surface  during  the  eruptive  period 
that  decay  will  be  avoided.  When  the  occlusal  surfaces  of  the 
teeth  of  the  jaws  so  approach  each  other  that  they  are  subjected 
to  the  friction  of  mastication  the  tendency  to  decay  is  thereby 
materially  lessened,  and  it  is  consequently  a  matter  of  much 
moment  to  prevent  decay  till  this  takes  place.  The  cement 
may  conveniently  be  forced  to  position  by  the  finger  of  the  opera- 
tor, as  was  advocated  in  the  treatment  of  deciduous  teeth,  and  con- 
siderable pressure  may  be  brought  to  bear  upon  the  filling- 
material,  so  that  every  indentation  on  the  occlusal  surface  is 
perfectly  filled.  This,  while  it  may  not  be  considered  a  very 
elegant  method  of  operating,  is  assuredly  a  most  effective  one, 
and  in  this  instance  utility  is  paramount  to  elegance. 

In  cases  where  occlusal  cavities  have  been  filled  in  this  way 
with  cement  the  teeth  should  be  examined  every  three  or  four 
months,  and  metal  fillings  inserted  as  soon  as  the  cement  wears 
away  and  the  conditions  in  the  mouth  make  it  possible  to  do 
more  permanent  work.  These  conditions  relate  to  expediency 
of  operation  and  to  the  increasing  fortitude  on  the  part  of  the 
patient  to  withstand  the  tedium  and  pain  necessary,  rather  than 
to  any  pronounced  change  of  structure  in  the  teeth.  That  a 
change  does  take  place  progressively  from  youth  to  age  is  without 
question,  but  it  is  neither  so  radical  nor  so  rapid  that  it  need 
be  accounted  an  important  factor  in  the  selection  of  a  filling- 
material.  Dr.  Black  showed  conclusively  that  all  enamel  and 
all  dentin  is  harder  at  any  age  than  any  of  our  filling-materials, 
and  this  should  be  sufficient  to  settle  the  question  so  far  as  it  has 
a  bearing  on  the  choice  of  material.  If  tooth-tissue  is  found 
which  is  softer  than  the  materials  we  use  it  is  due  to  pathological 
conditions  aside  from  dental  caries,  and  need  not  be  considered 
in  this  connection. 


280  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

As  to  the  choice  between  gold  and  amalgam,  this  should  be 
governed  by  two  considerations — the  one  of  expense  and  the  one 
of  an  adequate  endurance  on  the  part  of  the  patient  to  submit  to 
gold  operations  without  undue  nervous  strain.  It  should  be  the 
aim  of  all  operators  who  take  pride  in  their  work,  and  who  wish  to 
do  the  most  permanent  service,  when  they  have  the  care  of  the 
teeth  from  childhood,  to  keep  amalgam  out  of  the  mouth  entirely, 
but  this  does  not  seem  in  all  cases  to  be  possible.  We  must  not 
jeopardize  the  nervous  system  of  our  young  patients  in  the  blind 
effort  to  live  up  to  some  high  ideal,  no  matter  how  beautiful  it 
may  appear  to  us.  Neither  will  it  do  to  affirm  that  gold  should 
never  be  used  under  a  certain  age,  say  the  age  of  twelve,  as  we 
have  so  often  heard.  It  is  not  a  question  of  age  at  all.  It  is  a 
question  of  temperament,  a  question  of  physical  and  mental 
stamina  on  the  part  of  the  patient.  Some  children  at  a  given 
age  have  a  much  greater  capacity  for  enduring  operations  upon 
the  teeth  than  have  other  children  at  the  same  age,  and  every 
operator  should  make  a  careful  study  of  this  matter  among  his 
patients.  Since  the  introduction  of  the  cast  gold  inlay  the  prob- 
lem of  managing  these  cases  is  greatly  simplified.  By  its  use,  if 
the  cavity  is  of  sufficient  size  to  warrant  an  inlay,  these  cases  may 
be  met  more  acceptably  in  this  way  than  by  any  other  method. 
The  preparation  of  such  a  cavity  for  an  inlay  involves  very 
little  if  any  greater  tax  on  the  patient  than  for  an  amalgam 
filling,  and  the  resultant  operation  is  incomparably  better.  This 
is  only  another  instance  where  the  inlay  has  proved  a  distinct 
blessing,  and  has  given  us  the  ready  means  at  hand  to  greatly 
improve  our  service.  This  applies  as  well  to  all  classes  of  cavities 
in  children's  permanent  teeth,  where  the  decay  has  progressed 
sufficiently  to  warrant  an  inlay.  It  enables  us  to  successfully 
meet  a  large  number  of  these  cases  which  before  its  advent  gave 
us  much  concern. 

A  very  useful  material  for  filling  these  occlusal  cavities  where 
the  area  of  the  cavity  is  not  too  great  is  a  combination  of  gold 
foil  and  tin  foil  rolled  together.  This  can  be  used  when  the  gold 
operation  would  be  too  exhausting  and  where  the  cavity  is  too 
small  for  an  inlay.  If  properly  manipulated  it  will  prove  a  very 
satisfactory  and  often  a  very  permanent  operation.  With 
an  operator  who  is  familiar  with  its  manipulation  it  may  be 
inserted  so  rapidly  that  it  is  seldom  necessary  to  apply  the 
rubber  dam,  and  this  of  itself  is  often  an  important  item  in  the 


THE   MANAGEMENT    OF    CHILDREN'S    TEETH  281 

management  of  children's  teeth.  It  is  especially  indicated  in  oc- 
clusal cavities  of  upper  molars  and  bicuspids,  the  lower  molars 
ordinarily  calling  for  fillings  too  great  in  area  to  make  this  mate- 
rial serviceable.  It  cannot  be  depended  upon  to  wear  well  in 
cavities  with  a  broad  masticating  surface. 

There  is  one  point  upon  first  permanent  molars  which  calls  for 
the  most  careful  attention  in  the  early  period  of  their  eruption— 
viz.,  the  mesial  surface.  This  surface  is  in  contact  with  the  second 
deciduous  molar  for  several  years  before  the  loss  of  the  deciduous 
teeth,  and  if  the  tendency  to  decay  is  great  in  that  mouth,  or  if  the 
deciduous  molar  is  affected  on  its  distal  surface,  the  first  permanent 
molar  is  almost  certain  to  suffer.  It  is  well  in  many  of  these  cases, 
as  soon  as  the  permanent  tooth  is  fully  erupted,  to  grind  away  the 
distal  surface  of  the  deciduous  tooth  so  that  there  is  only  a  narrow 
contact  between  the  two.  In  this  way  the  mesial  surface  of  the 
permanent  molar  is  more  readily  kept  clean. 

In  case  decay  occurs  in  this  surface,  it  may  ordinarily  best  be 
controlled  during  the  presence  of  the  deciduous  teeth  with  gutta- 
percha. If  a  sufficient  depth  of  cavity  cannot  be  gained  to  secure 
the  gutta-percha  in  place,  it  is  best  to  flow  cement  over  the  sur- 
face as  a  temporary  expedient,  though  cement  on  these  proximal 
surfaces  must  not  be  depended  upon  for  any  length  of  service. 
The  patient  should  be  instructed  to  report  immediately  on  the 
loss  of  the  deciduous  molar,  and  whether  the  permanent  tooth  has 
been  filled  with  cement  or  gutta-percha  it  should  at  that  time  be 
replaced  with  gold  foil  or  an  inlay.  This  can  be  done  to  better 
advantage  before  the  eruption  of  the  second  bicuspid,  when  the 
mesial  surface  of  the  permanent  molar  is  freely  presented  to  the 
operator,  than  at  any  time  subsequently.  At  this  sitting  every 
vestige  of  affected  enamel  should  be  included  in  the  cavity, 
and  the  metallic  surface  be  made  sufficiently  broad  to  render 
the  operation  as  permanent  as  possible. 

In  cases  where  the  proximal  surface  is  so  decayed  that  the  oc- 
clusal surface  becomes  involved  before  the  operator's  attention 
is  called  to  it,  the  best  temporary  filling  is  ordinarUy  to  be  found  in 
a  combination  of  gutta-percha  and  cement,  laying  gutta-percha 
over  the  gingival  third  of  the  cavity  and  completing  the  filhng 
with  cement.  The  latter  will  probably  require  occasional  re- 
newal, but  the  gutta-percha  will  ordinarily  last  till  the  patient  is 
in  a  condition  to  have  a  permanent  operation  made. 

The  care  of  permanent  incisions  in  the  mouths  of  children  is  a 


282  PRINCIPLES    AND    PRACTICE    OF    FILLING    TEETH 

matter  calling  for  careful  consideration.  If  decay  occurs  very- 
early,  it  is  usually  best  to  resort  to  cement  or  gutta-percha,  in- 
stead of  attempting  permanent  work  at  the  outset.  The  choice 
between  gutta-percha  and  cement  must  be  governed  by  the  na- 
ture of  the  decay.  If  there  is  sufficient  penetration  to  securely 
hold  the  gutta-percha  in  place,  it  may  be  depended  on  for  more 
permanent  work  than  cement,  but  in  shallow  cavities,  too  sensitive 
for  much  cutting,  the  cement  may  be  maintained  in  place  more 
readily  than  gutta-percha.  Neither  of  these  materials  need  be 
considered  in  the  light  of  anything  but  temporary  expedients, 
and  the  patient  should  be  carefully  studied  and  judiciously 
schooled  toward  an  attitude  of  sufficient  fortitude  to  submit  to 
permanent  operations  as  early  as  may  seem  practicable. 

The  introduction  of  the  silicate  cements  has  furnished  us  with 
a  means  of  meeting  many  of  these  cases  more  acceptably  than 
in  any  other  way.  As  has  been  intimated  they  cannot  yet  be 
classed  as  permanent  when  compared  with  metal  fillings  or  inlays, 
and  yet  they  are  so  much  more  permanent  than  the  oxyphosphates 
or  gutta-percha,  and  so  greatly  in  advance  of  any  of  the  materials 
in  appearance,  that  they  are  especially  useful  in  the  class  of  cases 
under  consideration.  It  is  hoped  that  continued  improvement 
may  be  made  in  their  preparation,  to  the  end  that  their  useful- 
ness will  be  widely  extended. 


INDEX 


Adapting  a  matrix  to  the  cavity  in  a 

tooth,  216 
Amalgam,  143 

manipulation  of,  201 

method  of  packing,  203 
AnneaUng  gold,  151 
Appliances  for  examining  the  teeth, 

38 
Application  of  the  dam  in  difficult 

cases,  65 
Applying  the  dam  for  operations  on 

buccal,  labial,  or  lingual  cavities,  63 
Arsenic,  destroying  the  pulp  with,  242 
Automatic  mallet,  the,  166 


B 


Baking  the  porcelain,  220 
Bicuspids  and  molars,   cavities  in, 
92,  93,  120 
clamps  for,  47 
fillings  in,  184,  187 
Bleaching  teeth,  270 
Buccal,  labial,  or  lingual  cavities,  115 
applying  the  dam  for  opera- 
tions on,  63 
clamps  for,  49 
or  lingual  fillings,  193 
finishing,  194 


C 


Calculus,  salivary,  4 

serumal,  6 
Capping  pulps,  materials  for,  237 

method  of,  239 
Care  of  the  teeth,   instructions  to 

patients  as  to,  22 
Caries,  examination  of  the  teeth  for, 

37 


Casting,  228 

Cavities,  classification  of,  71 

Cavity  preparation,  72 

for  inlays,  detail  of,  212 
Cementing  the  inlay,  230 
Cements,  145 

manipulation  of,  206 
Cervical  clamps  for  buccal,  labial,  or 

lingual  cavities,  49 
Children's  teeth,   the  management 

of,  272 
Clamps,  kinds  of,  47 
Classification    and    preparation    of 

cavities,  71 
Cocain,       removal      of     the    pulp 

with,  245 
Cohesive    and    non-cohesive    gold, 

150 
Contact  point,  96 
Crystal  golds,  158    . 


D 


Deciduous    teeth,    management    of 
the,  272 
treatment  of  abscessed,  277 
of  exposed  pulps  in,  276 
Dental  caries,  25 
Dentin,  hypersensitive,  129 
Deposits  on  the  teeth,  1 

kinds  of,  4 
Destroying  the  pulp  with  arsenic,  242 
Destruction  of  the  pulp,  241 
Detail  of  cavity  formation  in  proxi- 
mal cavities  in  anterior  teeth 
involving  the  incisal  angle,  87 
in  proximo-occlusal  cavities  in 

bicuspids  and  molars,  106 
in    simple  proximal  cavities  in 
incisors  and  cuspids,  78 
of  cavity  preparation  for  inlays, 
212 
283 


284 


INDEX 


Different  forms  of  gold,  156 
Direct  and  indirect  methods  of  mak- 
ing inlays,  231 

E 

Examination  of  the  teeth  for  caries, 
37 

Examining    the    teeth,    appliances 
for,  38 

Exclusion  of  moisture  during  opera- 
tions, 40 

F 

Filled  teeth,  opening  into  where  the 
pulps  have  died  but  lain  dormant, 
269 
Filling  materials,  137 

pulp  canals,  249 
Finishing  buccal,  labial,  or  lingual 
fiUings,  194 
gold   fillings  on  the  occlusal  sur- 
faces of  bicuspids  and  molars, 
192 
proximal  fillings  in  incisors,    186 
proximo-occlusal    fillings    in    bi- 
cuspids and  molars,  186 
Fitting  the  matrix,  214 

G 

Gold,  150 

annealing,' 151 

and  its  combinations,  137 

and  platinum,  141 

and  tin,  142 

cohesive  and  non-cohesive,  150 

crystal,  158 

fillings,    the    introduction,     con- 
densation, and  finishing  of,  174 

for  casting,  227 

inlays,  223 
Gutta-percha,  146 

manipulation  of,  208 

H 

Hand  mallet,  the,  161 

pressure,  168 
Hypersensitive  dentin,  129 


Inlay  fillings,  making,  212 
Inlays,  148 

gold,  223 

porcelain,  212 
Instructions  to  patients  as  to  the 

care  of  the  teeth,  22 
Instruments  for  removal  of  salivary 

calculus,  10 
Interproximal  space,  the,  99 
Investing  the  wax,  226 


K 


Kinds  of  clamps,  47 
of  deposits,  4 
of  rubber  dam,  42 


Ligatures,  52 


M 


Making  gold  inlays,  223 

inlay  fillings,  212 
Mallets  and  malleting,  161 
Management    of    children's    teeth, 
the,  272 
of  permanent  teeth  in  childhood, 

the  277 
of  pulpless  teeth,   the  X-ray  in, 
256 
in    the    anterior    part    of    the 
mouth  to  prevent  discolora- 
tion, the,  270 
Manipulation  of  amalgam,  201 
of  cements,  206 
of  gold  and  tin,  197 
of  gutta-percha,  208 
of  platinum  and  gold  in  filling 
•     teeth,  195 
of  silicate  cements,  210 
Manner  of  applying  the  dam  in  the 
different  locations  in  the  mouth,  56 
Matching  shades,  218 
Materials  for  capping  pulps,  237 


INDEX 


285 


Matrix,  the,  214 
fitting  the,  214 

Method  of  capping  pulps,  239 
of  making  inlays,  direct  and  indi- 
rect, 231 
of  packing  amalgam,  203 

Moisture,  exclusion  of,  during  opera- 
tions, 40 


Napkins,  68 


N 


O 


Occlusal  cavities  in  bicuspids  and 
molars,  120 
fillings  in  bicuspids  and  molars, 
187 
finishing,  192 
Opening  into  filled  teeth  in  which 
the   pulps    have    died,    but    lain 
dormant,  269 


Pulp-canals,  filling  of,  249 

-capping,  234 
Pulp,  destruction  of  the,  241 

removal  of  the,  246 
Pulpless  teeth,  treatment  of,  261 


R 


Rapid  mallets,  167 
Removal    of    calculus,    instruments 
for,  10 
of  salivary  calculus,  9 
of  serumal  calculus,  15 
of  stains  from  the  teeth,  17 
of  the  pulp,  246 

with  pressure  anesthesia,  245 
Rolls,  cotton,  70 
Rubber-dam  clamps,  45 
Rubber  dam,  kinds  of,  42 

method  of  applying  in  different 

locations  in  the  mouth,  56 
punching  the  holes  in,  43 


S 


Pericemental  membrane,  protection 

to,  in  malleting,  171 
Platinum  and  gold,  manipulation  of, 

195 
Pluggers,  179 
Porcelain  bodies,  218 

inlays,  212 
Pressure   anesthesia,    removing   the 

pulps  with,  245 
Proximal  cavities  in  anterior  teeth 
involving  the  incisal  angle,  86 
in  bicuspids  and  molars,  92 
in  incisors  and  cuspids,  simple, 
72 
fillings  in  anterior  teeth  involving 

the  incisal  angle,  182 
gold  fillings  in  incisors,  simple,  175 
Proximo-occlusal  cavities  in  bicus- 
pids and  molars,  93 
for  gold  inlays,  221 
fillings  in  bicuspids  and  molars,  184 
finishing,  186 


Salivary  calculus,  4 

removal  of,  9 
Sensitive  dentin,  treatment  of,  126 
Separating  teeth,  75,  105 
Serumal  calculus,  6 

removal  of,  15 
Silicate    cements,    manipulation  of, 

210 
Simple  proximal  cavities  in  bicus- 
pids and  molars,  92 
in  incisors  and  cuspids,  72 
gold  fillings  in  incisors,  175 
Size  of  rubber  dam,  43 
Stains  on  the  teeth,  7 

removal  of,  17 


Taking  impression  of  the  cavity,  215 
Technique    of     removing     salivary 

calculus,  12 
The  automatic  mallet,  166 
The  hand  mallet,  161 


286  INDEX 

The  interproximal  space,  99  Treatment   of   abscessed   deciduous 

The  introduction,  condensation,  and  teeth,  277 

finishing  of  gold  fillings  in  different  of    exposed    pulps    in    deciduous 

classes  of  cavities,  174  teeth,  276 

The  silicate  cements,  147         .  of  pulpless  teeth  having  a  sinous 

The  treatment  of  pulpless  teeth,  261  opening  on  the  gum,  267 

The  use  of  napkins  and  cotton  rolls  where    the    canals    have    been 

for    maintaining    dryness    during  long  exposed  to  the  fluids  of 

operations,  68  the  mouth,  but  where  there  is 

The  X-ray  in  the  management  of  no  sinous  opening,  261 

pulpless  teeth,  256  of  putrescent  pulp  canals,  261 

Tin,  145  of  sensitive  dentin  in  deep-seated 

Tin  and  gold,  manipulation  of,  197  cavities,  126 


..'■•■(k;A'.l!*v./ 

COLUMBIA  UNIVERSITY  LIBRARY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,     , 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

bL^  .:  .. 

CSa(239)M100 

Johnson 


J  62 
1918 


Principles  and  practice  of  filling 


teeth. 

SE?22 


